
Class. 
Book. 



Copyright N°_ 



\<M3 



COPYRIGHT DEPOSIT. 



Principles and Practice of 
Infant Feeding 



BY 

JULIUS H. HESS, M.D. 

Professor and Head of the Department of Pediatrics, University of 
Illinois College of Medicine; Chief of Pediatric Staff, Cook County- 
Hospital; Attending Pediatrician to Cook County, Michael 
Reese and Englewood Hospitals, Consulting Pediatrician, 
Municipal Contagious Hospital, Chicago. 



ILLUSTRATED 



SECOND REVISED EDITION 




PHILADELPHIA 

F. A. DAVIS COMPANY, Publishers 

English Depot 

Stanley Phillips, London 

1919 






COPYRIGHT, 1918 
COPYRIGHT, 1919 

BY 

F. A. DAVIS COMPANY 



Copyright, Great Britain. All Rights Reserved. 



oct 3i \m 



PRESS OF 

F. A. DAVIS COMPANY 

PHILADELPHIA. U.S.A. 



©CI.A536U74 



o- 



TO 

ISAAC A. ABT, M.D. 

MY FRIEND AND TEACHER 
THIS BOOK IS AFFECTIONATELY DEDICATED 






(Hi) 



PREFACE TO THE SECOND EDITION. 



In the preparation of the second edition material 
changes have been made in the treatment of the Chapter 
on Artificial Feeding in that an absolute relationship 
between the quantity of the individual food elements of 
the diet and the requirements of the infant per pound 
body weight of fat, protein, carbohydrate, salts and water 
for growth and development are made the basis for 
preparation of diets. 

This establishes a fixed basis for comparative quanti- 
tative studies of relation of diet to growth and develop- 
ment independent of the size and frequency of feedings, 
and the percentage composition of the mixture. 

Julius H. Hess. 

Chicago, Illinois. 



(v) 



CONTENTS. 



Part I. 

GENERAL CONSIDERATIONS. „__ 

PAGE* 

Chapter I. The Anatomy of the Digestive Tract of the Infant 1 
Chapter II. The Physiology of the Digestive Tract of the 

Infant 4 

Chapter III. Metabolism in Infants 7 

1. General Considerations 7 

2. Composition of Milk and the Metabolism of its 

Constituents 8 

3. Milk Digestion 21 

Chapter IV. Bacteria of the Digestive Tract of the Infant.. 26 

1. The Newborn 26 

2. The Nursing Infant 26 

3. Artificially Fed Infants 27 

4. Significance of the Intestinal Bacteria 29 

5. Influence of the Diet on the Intestinal Flora 29 

6. Intestinal Bacteria in their Relation to Gastroin- 

testinal Disturbances 31 

Part II. 

THE NURSING. 

Chapter I. General Considerations 35 

Chapter II. Maternal Nursing 39 

1. Nursing Axioms 39 

2. Hygiene of the Mother 39 

3. Conditions Influencing the Breast Milk 42 

4. The Nursing Proper 43 

Chapter III. Wet-nursing 47 

1. The Wet-nurse; Her Selection and Her Baby 47 

2. The Hygiene of the Wet-nurse 54 

3. The Nursing 58 

Chapter IV. The Nursing Infant 64 

Chapter V. Mixed Feeding and Weaning 67 

(vii) 



viii CONTENTS. 

PAGE 

Chapter VI. Nutritional Disturbances in the Breast-fed 

Infant 71 

1. Underfeeding 71 

2. Overfeeding 76 

3. Congenital Debility, with Resulting Impairment of 

Vital Functions 84 

4. Intercurrent Parenteral and Enteral Infections 85 

5. Idiosyncrasy towards Mother's Milk 87 

Chapter VII. Methods of Feeding Premature Infants 89 

1. Infants Nursing at the Breast 89 

2. Infants too Weak to Nurse the Breasts 90 

3. Proper Time for Beginning Regular Feeding 96 

4. Feeding from the Second to the Tenth Day 97 

5. Feeding After the First Ten Days 99 

6. Number of Feedings Daily 100 

7. The Amount of Each Feeding 101 

S. Daily Gains 102 

9. Artificial Feeding 102 

10. Conclusions 105 



Part III. 

ARTIFICIAL FEEDING. 

Chapter I. Recent Progress in Artificial Feeding 107 

Chapter II. Cow's Milk 110 

Chapter III. Adaptation of Milk for Infant Feeding 124 

1. Undiluted Whole Milk 126 

2. The Percentage Method or System of Feeding 126 

3. Top Milk Feeding 127 

Chapter IV. Milk Dilutions with the Addition of Carbo- 
hydrates 129 

Chapter V. Feeding in Late Infancy and Early Childhood . . 166 

Part IV. 

NUTRITIONAL DISTURBANCES IN ARTIFICIALLY 
FED INFANTS. 

Chapter I. Minor Disturbances 170 

1. Stationary Weight 170 

2. Vomiting 170 

3. Colic and Flatulence 171 

4. Constipation 172 

5. Abnormal Stools 173 

6. Milk Idiosyncrasy 175 



CONTENTS. ix 

PAGE 

Chapter II. General Consideration of Nutritional Disturb- 
ances 177 

Chapter III. Disturbed Metabolic Balance 188 

Chapter IV. The Stage of Dyspepsia 198 

Chapter V. The Stage of Decomposition 209 

Chapter VI. The Stage of Alimentary Intoxication 225 

Chapter VII. Mixed Forms of Nutritional Disturbances 239 

Chapter VIII. Nutritional Disturbances Due to Insufficient 

Food 240 

Chapter IX. Infection and Nutrition 247 

1. Susceptibility Influenced by Nutrition , 247 

2. Course of Infections Influenced by Nutrition 248 

3. Infection Influencing Nutrition 249 

(A) Parenteral Infections 250 

(B) Enteral Infections " 256 

Appendix. 

Proprietary Baby Foods , . 275 

Directions for the Preparation of Infant's Foods 281 

Bottles and Nipples and their- Care 297 

Care of Food During Traveling 299 

The Diaper 300 

Baby's Daily Bath 302 

Cold Bath and Cold Pack 304 

Hot Bath 305 

Mustard Bath and Mustard Pack 305 

Stomach Washing 306 

Catheter Feeding by Mouth 307 

Catheter Feeding by Nose 308 

Irrigation of the Colon and Rectal Feeding 308 

Saline Solutions 310 

Electrically Heated Water Jacketed Infant Bed 312 

Home-made Ice-box 316 

Case History , 316 

Average Weights 318 

Measurements 318 

General Development 319 

Sleep 319 

Order and Average Time of Eruption of the 20 Deciduous 

Teeth 319 



x CONTENTS. 

PAGE 

Permanent Teeth 320 

Closure of Fontanels 320 

Average Daily Quantity of Urine in Health 321 

Average Rate of Pulse and Respiration 321 

Blood-picture in Healthy Children 321 

Average White Cell Counts — 321 

Stool Symbols ■....-.- ......... 322 

Urine Symbols . . 322 

Record Sheet 322 

Index 329 



Part I. 

General Considerations. 



CHAPTER I. 

THE ANATOMY OF THE DIGESTIVE TRACT 
OF THE INFANT. 

Oral Cavity. The salivary glands are well developed 
at birth, and the active principles of the salivary secre- 
tion are present, but in small quantities. Teething begins 
at about the sixth month, and dentition is not completed 
until about the end of the second year. In most instances 
this is a normal physiological process, and should cause 
no disturbances. However, in a considerable number of 
cases the gastric and intestinal secretions are affected re- 
flexly, with a diminished activity on the part of these 
glands ; and if there is any tendency to a general disturb- 
ance during this period, a reduction in the quantity of the 
food administered is indicated. However, far too great 
an importance is usually given by the laity to the process 
of teething. 

Stomach. In the newborn the stomach has a more 
vertical position than in the adult. However, rontgen- 
ologic examination has demonstrated that it is less ver- 
tical than has been formerly supposed. The cardiac end 
is found at the left of the tenth dorsal vertebra. The 
pylorus lies about midway between the ensiform cartilage 
and the umbilicus. The position of the stomach and its 
form, due to lack of development of the fundus and lack 

a) 



2 INFANT FEEDING. 

of muscular development at the cardiac end, account in 
great part for the frequency of vomiting in the infant. 

The pylorus also lacks the muscular development of 
the adult, and is decidedly more patent. ♦ 

Considerable difficulty is experienced in our attempts 
to gain accurate knowledge of the capacity of the stom- 
ach. Pfaundler, who measured the size of numerous 
infants' stomachs, using air under a given pressure, has 
given us figures which are, in all probability, fairly 
accurate. 

He states that the capacity at birth is 2 ounces (60 
mils), at one month 2 to 3 ounces (60 to 90 mils), at six 
months 6 ounces (180 mils), and at one year 9 to 10 
ounces (270 to 300 mils). The importance of the stom- 
ach's capacity in determining the size of the individual 
feeding is only relative, dependent to ia great extent upon 
the form of diet. With milk as the food, a considerable 
portion of the water content passes through the pylorus 
before the meal is finished, if the food is not too rapidly 
given. When a child is fed by gavage, the size of the 
meal is of greater importance because of the danger of 
overdistention by the rapid administration of the food by 
this method. Notwithstanding the fact that the size of 
the stomach varies in different babies, we have found it a 
good working rule in the feeding of normal infants to 
administer at each feeding a quantity 2 ounces more of 
the liquid food than the infant is months old. 

The intestines are relatively larger than in the adult, 
which applies more especially to the large intestine, and 
particularly to the sigmoid flexure. The sigmoid is also 
more mobile, due to the greater length of the mesosig- 
moid, and is extra-pelvic. The musculature is rela- 
tively thin, and bears an important relationship to the 



ANATOMY OF THE DIGESTIVE TRACT. 3 

frequency of its overdistention and the presence of colic, 
which is due to the stagnation of large quantities of gas 
in the intestinal tract. 

The pancreas shows no special anatomical differences. 

The liver is relatively two-and-a-half times as large 
at birth as in the adult, and is easily palpable, and in the 
nipple-line of the right side usually extends 1 to \y 2 
inches (2 to 4 cm.) below the costal border. 



CHAPTER II. 

THE PHYSIOLOGY OF THE DIGESTIVE 
TRACT OF THE INFANT. 

While all the ferments are present in early life, they 
vary quantitatively and qualitatively as compared with 
older children. 

Mouth. Ptyalin, which is an amylolytic ferment, is 
present in the saliva immediately after birth, but is small 
in amount, and weak in its action. Albumin, water and 
mucus in saliva vary with the variety of food taken 
(Pavlow). 

Stomach. Gastric juice is present in the stomach 
even in the premature. Its secretion is mainly stimu- 
lated by the act of sucking and by the presence of the 
food in the stomach. 

Free hydrochloric acid is little less than in the adult. 
It may be stated that the small protein content of human 
milk, as compared with cow's milk, favors the presence 
of hydrochloric acid. This is a point of great importance 
in the food problem of the infant. Free hydrochloric 
acid is found in 10 per cent, of cases after 1 hour, and in 
33 per cent, of cases after lj^ hours on feeding with 
human milk (Hamburger and Sperck). With cow's 
milk, free hydrochloric acid is found very rarely, which 
is due to combination of the hydrochloric acid with salts 
and proteins. Total acidity is in small part only due to 
free hydrochloric acid. More important are phosphoric 
acid, acid phosphates, acid chlorides, fatty acids and acid 
albumins (albumoses and peptones). Total acidity is 20 
to 60 mils N :10 acid to 100 mils of gastric contents. The 
(4) 



PHYSIOLOGY OF THE DIGESTIVE TRACT. 5 

action of the hydrochloric acid is as follows: (1) it 
makes protein digestion possible (acid albumins) ; (2) 
stimulates the pancreas; (3) disinfects and exerts anti- 
toxic action. 

The following ferments are present in the stomach : 
(1) Pepsin, which is present at birth, and is active and 
causes at least partial digestion of proteins. It increases 
to the fourth month, then remains fairly constant. More 
pepsin is present in bottle-fed infants. (2) Rennin is 
also present at birth, and in the presence of hydrochloric 
acid coagulates milk. Whether this is dependent on pep- 
sin, or whether it is a specific ferment, is questionable. 
(3) Lipase, a fat-splitting ferment, is found in the stom- 
ach in small quantities, and is probably a definite product 
of the gastric mucosa. 

Small Intestines. Mucous membrane of the small 
intestines secretes about 1 liter of juice daily, and this 
contains all ferments at birth, they being, however, rela- 
tively feeble at first. The following ferments are pres- 
ent in the intestinal secretion: (1) erepsin (Cohnheim), 
which splits casein, albumoses, and peptones to peptids 
and amino-acids. Other albuminous bodies are not 
affected by it. (2) lactase, malt as e, invertin; they split 
disaccharides (milk, malt, and cane sugar) to monosac- 
charides, and each is stimulated by its own sugar. (3) 
prosecretin, which is changed to secretin by hydrochloric 
acid from the stomach, and stimulates the secretion of 
the pancreas. (4) enterokinase, which activates the pro- 
teolytic enzyme of the pancreatic juice; and probably (5) 
diastase. 

Pancreas. All of the ferments (trypsin, steapsia, 
and amylopsin) are found in the intestines at birth. 



6 INFANT FEEDING. 

The liver possesses the ability to form glycogen and 
urea in the newborn. Bile is present, its emptying from 
the gall-bladder being stimulated by chemical action of 
fats on the duodenal mucous membrane. The functions 
of the bile are: (1) to hold fatty acids and fatty acid 
salts in solution, (2) to stimulate the pancreas, and (3) 
an antiseptic action. Other functions of the liver are 
formation of urea, and formation and storing of 
glycogen. 

Large intestines secrete no enzymes, their chief 
function being absorption of water and throwing off of 
Ca, P, Na, K, Fe, Mg. 



CHAPTER III. 

METABOLISM IN INFANTS. 

1. General Considerations. 

The term metabolism covers all of the functions of 
the human body which have to do with the preparation 
for and assimilation of food. 

To furnish the body with fuel for its normal activities, 
the following groups of food elements are necessary: 
proteins, fats, carbohydrates, salts, and water. Fats and 
carbohydrates, and to a lesser extent proteins, furnish 
fuel; while the proteins and salts more especially form 
the elements necessary for body growth. 

It is necessary to distinguish between the activities 
which take place within the gastro-intestinal tract before 
absorption of the changed products and the deeper seated 
metabolism which takes place beyond the intestinal wall, 
which can be designated as the "intermediary me- 
tabolism." 

Under normal conditions in the adults the intake and 
the products of excretion balance one another, while in 
the infant there is a positive balance — that is, less is ex- 
creted than is absorbed — and one may well say that a 
balance which would be normal in the adult is patho- 
logical in the child, and would thereupon soon result in 
a stationary weight, or a loss in weight. 

Several factors offer difficulties in the study of infant 
metabolism. 

First, it is difficult to obtain stools free from urine and 
r with the water content intact. 

Secondly, the small volume in which the urine and 
stools are obtained offers many difficulties in their study. 

(7) 



8 INFANT FEEDING. 

Urine and stool examinations should cover a period of 
at least three days to be of conclusive value. 

2. Composition of Milk and the Metabolism 
of Its Constituents. 

The natural food of the infant is human milk, char- 
acterized by the fact that its quality changes very little, 
the infant's growth being dependent on the increase in 
amount of milk secreted. 

Milk of different animals varies as to its fuel value, 
and also in its chemical composition, especially quan- 
titatively there being marked differences. 

Protein Fat Sugar Salts 

Human 1.5 3.5 6 to 7 0.20 per cent. 

Cow's 3.4 3.8 4 to 5 0.75 " " 

Human colostrum differs from the mature human milk 
in that the protein and salts are higher. Protein aver- 
aging 2.25 per cent., and the average ash 0.3077. Sugar 
not differing greatly from that the later milk, but aver- 
aging somewhat lower. Fats are also somewhat lower, 
averaging 3.15 per cent. (Holt *). These figures vary 
in different women, and also with the day of puerperium, 
but represent average specimens. Colostrum also con- 
tains numerous leucocytes, and large cells containing fat, 
these latter probably being epithelial in origin. 

1. Proteins. Chemistry of Proteins. Proteins con- 
tain carbon, hydrogen, nitrogen, oxygen, sulphur, and 
phosphorus. They are highly complex chemical sub- 
stances, similar in their chemical composition to proto- 
plasm and essential to life. 

Of the proteins milk contains mainly casein and al- 
bumins, with small amounts of globulins, opalisin, 
nuclein, etc. 



* Amer. J. Dis. Child., Vol. X, p. 228, October, 1915. 



METABOLISM IN INFANTS. 9 

100 mils of milk contain Albumin Casein 

Human milk 0.6 Gm. 0.8 Gm. 

Cow's milk 0.2 to 0.3 Gm. 2.7 to 3.0 Gm. 

Casein belongs to the nucleo-albumin group (proteins), 
which contain phosphorus, are insoluble in water, mod- 
erately in alkalies, precipitated by acids, not coagulated 
by boiling, and by pepsin digestion changed to para- or 
pseudo- nucleins (which are bodies rich in phosphorus). 
Chemically it is composed of a complex group of amino- 
acids, the basis of all protein bodies, and a prosthetic 
group which contains the phosphorus. Amino-acids are 
characterized by the group COOH, in which an H is re- 
placed by NH 2 group, e.g., acetic acid (CH 2 HCOOH), 
amino-acetic acid, or glykokoll (CH 2 NH 2 COOH). 

Human casein contains much less phosphorus than 
cow's (0.25 to 0.88). This proves that the casein of the 
human and the casein of the cow's milk are different 
bodies, although this difference is probably of a quanti- 
tative nature only. The two caseins differ also in their 
coagulability, the human casein being more difficult to 
precipitate with acids, salts and rennin. The soluble 
albumins are coagulated by heat and weak acids. 

Metabolism of Proteins. Casein is separated from the 
so-called whey albumin, and is changed to an insoluble 
paranuclein. It is unknown whether the enzyme causing 
it is identical with the protein digestive ferment of the 
gastric mucous membrane or not. 

Pepsin (from the pyloric mucous membrane) changes 
paranucleins to albumoses and peptones, which then pass 
into the small intestines. (Erepsin, the ferment of the 
intestinal juices, works very rapidly on the end products 
of pepsin digestion.) In the small intestine an intricate 
splitting takes place. 



10 INFANT FEEDING. 

With the human milk as a food, a very small amount 
of nitrogenous products of the food appears in the stools, 
the total being about one-sixth of the intake, and part of 
this arises from 

1. Intestinal juices,' 2. Intestinal epithelium. 
3. Bacterial activity. 
After passing through the intestinal wall, proteins have 
three functions to perform : 

1. To replace used proteins (lost through urine, sweat, 
digestive juices, cell destruction, etc.). 

2. To satisfy cell growth which would be impossible 
without proteins. 

3. To furnish fuel for part of the dynamic loss (fats 
and carbohydrates are the natural fuels, the protein com- 
bustion being of secondary importance). 

In the average feeding with cow's milk, three times as 
much protein is given as needed for 1 and 2, therefore 
it is used for 3, (that is, dynamic purpose), or is rejected 
by the body. 

The great disproportion as seen in a comparison of 
the proteins in cow's milk over human milk is probably 
due to the needs* for cell growth in the calf. Due to the 
ability of the organism, within certain limits to regulate 
its function, the excess of protein in the average diet 
with cow's milk as a basis is excreted by way of the 
intestinal tract. Cell growth is therefore not excessively 
stimulated on these relatively high protein diets. 

End Products of Protein Metabolism in Urine: 
Urea 60 to 80 per cent. Ammonia 3 to 10 per cent. 
Oxaluric bodies 



Uric acid 
Kreatinin 
Oxybutyric acid 



> Nitrogenous by-products. 



METABOLISM IN INFANTS. 11 

Urea forms 75 to 86 per cent, of the nitrogen con- 
stituents of the urine. 
By ammonia coefficient is meant the relation of am- 
monia to the other nitrogenous bodies in the urine. 
Influence of the Carbohydrates and Fats on the Nitro- 
gen Metabolism. 

1. Carbohydrates cause 

(1) Increased retention of proteins. 

(2) Increased nitrogen in feces. 

2. Fats cause ' 

(1) No increased protein retention. 

(2) Increased nitrogen in feces. 

2. Fats. Chemistry of Fats. Human milk fats are 
esters of palmitic, stearic, and oleic acids with glycerin, 
the oleic acid ester being present in larger amount in 
human than in the cow's milk. Human milk fats are de- 
rived partly from body fat and partly from food fat. 
Carbohydrates also furnish ingredients for fat making; 
proteins do not. 

Metabolism of Fats. 

1. Lipase from the gastric mucous membrane causes 
some splitting of fat. 

2. Fats are emulsified in small intestines. 

3. Live intestinal cells can change fatty acids to fats. • 
Resorption. 

1. Lymph-vessels. 

2. Blood-vessels. 
Disposition. 

1. Subcutaneous tissue. 

2. Preperitoneal spaces. 

3. Liver. 



12 INFANT FEEDING. 

4. Burned with resulting end products. 
(1) Carbonic acid. (2) Water. 

In stools found normally as unresorbed portion of in- 
gested fat in the form of 

1. Fat (neutral). 2. Lecithin. 3. Cholesterin. 

4. Fatty acids representing 1 to 10 per cent, of fat 

ingested. 

5. Alkali soaps. 6. Earthy alkali soaps. 

In Urine. Fatty acids and glycerin are found in very 
small quantities, but we cannot say that these are from 
the fats ingested. 

Nursing babies always have at least a small amount of 
fat in their stools. In contradistinction to proteins, the 
fats in the stools are in greater part only unresorbed fats, 
only a small amount being due to cell activity. (Proteins 
greater part). 

- Various percentages of fat ingredients found by 
Klotzin* examination of breast milk stools are as follows : 

Neutral fat 29.5 per cent. 

Fatty acids 10.7 " " 

Combined fatty acids .... 58.8 " " (18.3 Ca and Mg.) 

While under normal conditions 18.3 per cent, of the 
fats in the stools exist as non absorbable fat soaps in 
the so-called fat soap stools, they will approximate 50 
per cent, of calcium and magnesium soap. 

Fat in the G astro-intestinal Tract and its Relation to 
Metabolism. Unlike proteins we can nourish the in- 
dividual without fats, as carbohydrates can replace them. 
If too long continued, the organism changes, however, in 
its chemistry through increased absorption of salts and 
water. 



* Langstein-Meyer : Weisbaden, Verlag von J. F. Bergmann. 
Third edition, p. 16. 



METABOLISM IN INFANTS. 13 

3. Carbohydrates. Milk sugar formed by the mam- 
mary glands from material circulating in the blood is a 
disaccharide (glucose and galactose). 

Chemistry of Carbohydrates. 

1. Monosaccharides. 

(1) Glucose (dextrose, grape sugar). 

(2) Lsevulose (fruit sugar). 

They ferment and are reducible. (1) Has 
a right and (2) left polarization. 

2. Disaccharides. 

(1) Lactose — glucose and galactose. 

(2) Maltose— glucose and glucose. 

(3) Saccharose — glucose and lsevulose. 
(1) and (2) are reducible, (3) is not. 

3. Polysaccharides (three or more sugar molecules). 

(1) Flour. 

(2) Dextrin. 

(3) Cellulose. 

Metabolism of Carbohydrates. Monosaccharides are 
without further change absorbed in the small intestine 
or fermented. 

Disaccharides are first reduced to monosaccharides by 
the intestinal ferments (every disaccharide having its 
specific ferment) before they can be absorbed. (This is 
not entirely true of maltose). 

Polysaccharides are first acted upon by ptyaline in the 
saliva ; this is continued in the stomach until the stomach 
content becomes acid, and then by enzymes of intestines 
and pancreas they are converted to monosaccharides. 

After absorption into the blood, the carbohydrates 
serve the following purposes : 



14 INFANT FEEDING. 

1. Used for energy. 

2. Synthetically inverted into glycogen. 

3. Fat foundation (probably). 

Body cells can oxidize only monosaccharides (maltose 
excepted). 

Interesting is the storing up of glycogen by the liver 
and muscles so that the sugar in the blood can be kept 
constantly at about 0.1 per cent. 

Glycogen is most easily made from glucose and laevu- 
lose; less so from galactose, maltose and starch; least 
easily from cane and milk sugar.* f 

Fat is formed from sugar by the subcutaneous cells, 
which are especially adapted to this function, f 

Sugar is oxidized to carbon dioxide and water, which 
can be measured by the respiratory metabolism. Nor- 
mally, sugar is absorbed from the small intestines, and 
is not found in the feces. 

Sugar appears in the urine when the capacity for 
assimilation is passed, thereby producing an alimentary 
glycosuria. This is most easily accomplished in the 
following order: lactose, galactose, laevulose, glucose. 
The cane sugar limit is about the same as milk sugar, 
while that of malt sugar is 77 grams per kilogram body 
weight. The assimilation limit for sugars is much 
greater in infants than in adults. An infant may develop 
mellituria when milk sugar exceeds 3.1 to 3.6 grams 
per kilogram body weight; in the adult at over 1 gram 
per kilogram. The height of the assimilation limit in 
itself shows that the infant's organism is adapted to a 
higher carbohydrate metabolism than that of the adult. 



* Otto von Furth : Physiological and Pathological Chemistry 
of Metabolism. J. B. Lippincott Company, p. 227-230. 
t Langstein and Meyer : Third Edition, p. 16. 



METABOLISM IN INFANTS. 15 

Carbohydrates in the Tissues. The newborn has a gly- 
cogen depot. 

Carbohydrates can, in part at least, replace proteins 
and fats. They cause a rapid increase in weight (very 
rapid at first), being deposited in the tissues, as glycogen, 
which latter can absorb two to three times its weight of 
water. 

The relation of fats to carbohydrates is as follows: 

The more carbohydrates present, the greater is the ten- 
dency on the part of the system to build up body fats. 
As to oxidation of fats, "They are burned up in the fire 
of carbohydrates'' (Naunyns). 

The complete burning of fats into carbon dioxide and 
water takes place only when the carbohydrate metabolism 
is normal ; otherwise we get as mid-products the acetone 
bodies (acetone, aceto-acetic acid, oxybutyric acid, etc.). 

They occur most frequently in infancy and childhood 
following periods of underfeeding or starvation. (Im- 
portant in infants' disease, as seen during weaning, 
anorexia, continued fevers, intoxication, etc.) 

Acetone bodies can also be formed from protein mole- 
cules. This occurs in starvation and in excessive meat 
and fat diets (deficiency of carbohydrates in the latter). 

Weight becomes stationary or a loss results when car- 
bohydrates are excluded or insufficient in the diet. Tem- 
perature falls, and does not rise to normal until they are 
replaced. 

4. Salts. Chemistry of Salts. Salts added to water 
are relatively split into their "ions" — that is, into either 
electrically positive or negative bodies. A solution of 
sodium chloride is a solution in which the NaCl molecule 
is intact, but the Na (kation) is electro-positive; the CI 
(anion) is electrically negative. 



16 INFANT FEEDING. 

Mature human milk contains 0.2 Gm. ash in 100 mils. 
Cow's milk 0.75 Gm. ash in 100 mils. Some exists as 
inorganic salts, others as important organic compounds. 

I. Rations (or cations). 

1. Calcium. 

(1) Human 0.458 Gm. per 1000 mils, cow's 1.72 

Gm. per 1000 mils, about 1 : 4. 

(2) Excretion is almost entirely through intes- 

tines, some from unabsorbed food rem- 
nants, and the rest by tissue metabolism. 

2. Magnesium. 

(1) Human 0.074 Gm. per 1000 mils, cow's 

0.2 Gm. per 1000 mils. 

(2) Its metabolism is very closely related to the 

calcium. 

3. Sodium. 4. Potassium. 

(1) Human milk 0.132 Gm. Na 2 0, cow's 0.465 

Gm. Na 2 per 1000 mils, 1 : 3. 

(2) Human milk 0.609 Gm. K 2 0, cow's 1.885 

Gm. K 2 per 1000 mils, 1 : 3. 

(3) Excretion mostly through kidneys and 

stools. 
5. Iron. 

Human milk 0.0017 Gm. cow's 0.0007 Gm. per 
1000 mils. These figures show consid- 
erable variation according to different 
authors. Excreted mainly through the 
bowels. 

II. Anions. 

1. Chlorine. 

Human 0.358 Gm., cow's 0.82 Gm. per 1000 
mils. 1 : 3. 



METABOLISM IN INFANTS. 17 

(1) Absorption: 90 to 100 per cent, through 

the intestine. 

(2) Excretion: mostly through kidneys. 

(3) About 0.5 per cent, retained by the system. 
2. Phosphorus is contained in the milk in the fol- 
lowing forms: 

(1) Inorganic (calcium phosphate). 

(2) Organic (casein, nuclein, lecithin, etc.). 

(3) Total in human 0.345 to 0.418 Gm., in cow's 

2.437 Gm. per 1000 mils, 1 : 9. 

(4) Organic in human 43.3 per cent., and cow's 

46 per cent., 1:1. 

(5) The retention is higher in artificially fed 

than those fed on human milk. 

Relation of Salts to Metabolism. The salts are neces- 
sary in digestion and in every step of metabolism from 
absorption to excretion and secretion. The role of^these 
salts in both normal and pathological conditions has been 
given constantly increasing importance in the last few 
years. 

Metabolism of Salts in Infants. In the gastrointes- 
tinal tract the foods and salts are constantly changing 
action. 

A casein product and calcium combine in the stomach 
to form calcium paracasein. 

Fatty acids and alkalies and earthy alkalies in the intes- 
tines form soaps. 

Casein increases excretion of salt in the intestine 
(moderate). 

Fat increases excretion of salts in the intestines 
markedly, (especially Ca, Na, K). At the same time the 
phosphorus excretion decreases as the calcium phosphates 
are changed to calcium soaps by combination of calcium 

2 



18 INFANT FEEDING. 

with fatty acids, and the free phosphoric acid unites with 
sodium and potassium to form easily absorbed salts. 

Salts are excreted in the urine and stools. The stools 
are the main source of excretion of calcium, magnesium, 
and iron. Whether these are formed from the tissues or 
unabsorbed food is difficult to decide. The difference in 
percentages in human and cow's milk is equalized by the 
body using only what is necessary to its life and growth 
and not attempting to use it all. 

Functions of Salts. 

(1) They furnish building material for new cells. 

(Rachitis due to lack of absorption.) 

(2) They are necessary to nerve excitability, muscle 

contraction, and many other vital functions. 

(3) Addition of calcium and potassium to normal 

salt solutions counteracts their poisonous 
effects. 

(4) Life is incompatible with withdrawal of min- 

erals or even one ion. 

(5) Life does not so much depend upon the ion as 

on its chemical combination. Therefore ash 
alone will not supply the needs. 

(6) Infants need minerals for growth, as well as 

for life. Different tissues require different 
amounts and different salts. 

(7) Weight drops with withdrawal of salts, even 

if other ingredients are constant, due to loss 
of water. Sodium salts are most important 
in water retention, calcium salts are least. 

(8) Temperature falls, when salts are withdrawn 

(sodium). 

(9) Phagocytosis is increased by calcium salts. Of 

value in infection. 



METABOLISM IN INFANTS. 19 

5. Water, Infants need 105 Gm. of water, and adults 
40 Gm. of water, per Kg. 

Metabolism of Water. Intake is in the food. The 
outgo from the kidneys, bowels, lungs, and skin. 

Water when ingested quickly passes through the stom- 
ach to be absorbed by the intestines. The water content 
of the organism varies with age and food. In the adult 
58 per cent, of body is water, and in the newborn infant's 
body 66 to 69 per cent, is water. Sodium salts have the 
greatest facility for water retention. 

Of the anions, CI is the most marked in causing water 
retention. 

Excretion of water takes place as follows : kidneys 59 
per cent., skin and lungs 33 per cent., intestines 6 per 
cent. One to 2 per cent, of the water intake is retained. 

Relation of Water to Metabolism. Approximately 
two-thirds of the body is water. All cells need it; it is 
necessary to different combinations and reactions. In 
general, it is necessary for young infants on artificial 
feeding to receive about 140 to 150 mils (4 to 5 ounces) 
per kilogram (2 pounds) body weight every twenty-four 
hours. It carries nutritious material in the blood, lymph, 
cells, etc., and also the material for anabolism and kata- 
bolic products. It is also necessary to the function of the 
lungs and of the skin. It is deeply involved in the 
question of immunity. 

6. Lipoids. Proteins and lipoids form the principal 
component parts of all living cells. The lipoids are a 
group of organic nitrogenous substances comprising the 
phosphatids, cerebrosids and cholesterin. The phospha- 
tids contain phosphorus, an organic base, and a fatty 
acid radicle in their molecule. The members of this 
series are lecithin, cephalin and cuorin. They are widely 



20 INFANT FEEDING. 

distributed in both animal and vegetable cells, but are 
especially abundant in the yolk of eggs, fish roe, brain 
tissue, yeast, blood and bile. They are also found to 
a lesser extent in cereal grains, legumes and beet root. 
The cerebrosids are isolated almost entirely from brain 
and nerve tissue. These do not contain phosphorus and 
yield galactose upon hydrolysis with dilute mineral acids. 
Cholesterin is an unsaturated secondary alcohol, is uni- 
versally present in animal and vegetable tissue, and is 
most abundant in bile, yolk of eggs, nerve tissue and 
wool fat, and found abundantly in wheat, barley, beans, 
peas, lentils, carrots, peanuts and beets. 

Lecithin. Lecithin is the fatty acid ester of the glycero- 
phosphates (glycerin phosphoric acid), Human milk, 
0.499 Gm. per 1000 Gm. ; cow's, 0.63 Gm. per 1000 Gm. 
The organism can apparently live without it in its food. 

Cholesterin. Human milk, 0.25 to 0.38 Gm. per 1000 
Gm. Mainly excreted by the intestines. 

This is of interest when we consider that fat-free milk 
contains but little lipoids. 

7. Vitamines. Vitamines, or other substances the 
nature of which is quite obscure, seem likewise essential 
to growth and maintenance of normal nutrition. While 
as yet opinion is not unanimous in regard to their nature, 
it seems probable that they contain basic nitrogen, and 
that they are of such importance that their absence pro- 
duces certain diseases aptly called deficiency disease, as 
beri-beri, and pellagra. Scurvy, a disease of malnutrition 
which may be cured by a diet of anti-scorbutic foods, 
such as limes, lemons, oranges, may prove to be caused 
by vitamine deficiency. Vitamines are the mother sub- 
stances of ferments and hormones? They are of vital 
importance to the thyroid and other endocrin glands. 



METABOLISM IN INFANTS. 21 

Yitamines occur in plants, and more especially in their 
seeds, in whole wheat, whole corn, unpolished rice, 
fresh tomatoes, fresh legumes, most fresh fruits and 
their juices. Yeast is also rich in vitamines. Human 
milk, cow's milk, butter, cheese, eggs and beef contain 
vitamines. 

3. Milk Digestion. 

1. In the Mouth. In the mouth milk is mixed with 
saliva, each 100 mils of milk averaging about 5 mils of 
saliva (Tobler). The secretion of saliva is stimulated 
mainly by the act of sucking, but also in part by appetite 
(psychic reflex). Ptyalin begins its action on the carbo- 
hydrates of th£ milk. Saliva may also cause coagulation. 

2. In the Stomach. In the stomach the milk is 
curdled, casein being precipitated by rennin. Human 
milk coagulates less rapidly and less completely than 
cow's milk. Therefore in the latter the curds and the 

' whey are more quickly separated. 

Proteins are changed to albumoses and peptones by 
pepsin, and thus they are prepared for further digestion 
in the intestine. Albuminous digestive products stimu- 
late gastric secretion. 

Of fats 25 per cent, are changed to fatty acids and 
glycerin by lipase and action of bacteria. Fats at first 
retard, and later increase, the gastric secretion. 

Action of ptyalin on Carbohydrates is continued for a 
time in the fundic end of the stomach. 

Absorption in the stomach is as follows: (1) salts and 
sugars, (2) proteins (small amounts), (3) water (none), 
(4) fats (none). 

Shortly after beginning of the nursing some of the 
whey content of the food begins to leave the stomach. 
This is more especially true if the ferments are active. 



22 INFANT FEEDING. 

The time also varies with the quality of the meals. 
Human milk leaves the stomach in about one and one- 
half to two hours after ingestion, and cow's milk in about 
three hours after ingestion. Two factors have an impor- 
tant bearing on this point: (1) the quantity of the fat, 
which delays the passage of the food through the pylorus, 
(2) the size of the curds, the large curds of the cow's 
milk delaying emptying of the stomach. 

As previously stated, whey quickly passes out of the 
stomach, and remaining curd is digested at the surface, 
and this passes over. Solid masses may pass through. 
After each passage of food the pylorus again closes. The 
rapidity of emptying the stomach depends on the action 
of the pylorus, and this in turn on the chemical composi- 
tion of the food. Fats and albumins remain long in the 
stomach, sugars and salts passing through more rapidly. 

3. In the Small Intestines. The action of the gastric 
digestion on the proteins is supplemented by trypsin from ' 
the pancreas, and the erepsin of the succus entericus. 
End products of the protein digestion are amino-acids. 
Carbohydrates are split into monosaccharides in the 
small intestines and are absorbed there. Fats which have 
been split into fatty acids and glycerin are emulsified and 
absorbed. Absorption of all digested food is almost 
complete in small intestines. It may be stated, that intes- 
tinal or pancreatic digestion is far more important than 
gastric digestion in the infant. 

4. In the Large Intestines. Absorption of water and 
excretion of salts are the chief functions of the large 
intestines in the digestive process. 

5. Feces and Urine. Feces is composed of food rem- 
nants, products of secretory activity of the intestines, 
products of desquamation of the intestines and bacteria. 



METABOLISM IN INFANTS. 23 

Composition of feces depends to a certain extent upon the 
nature of the food ingested. Foods rich in proteins 
(skim milk, albumin milk, etc.) cause increased intes- 
tinal secretion, with resulting alkaline reaction, which 
favors putrefaction and furnishes conditions favorable 
for development of fat soap stools. Excess of carbohy- 
drates with acid fermentation gives another picture. 
Putrefaction and fermentation work antagonistically on 
the reaction of the stool. There is a balance between the 
acids derived from fat and sugars by bacterial action and 
the alkaline intestinal secretion. 

Proteins in the stool (giving biuret and Millon's tests) 
are in greater part not derived from food proteins, but 
they are due to intestinal secretions, desquamated epi- 
thelial cells of the intestines, and to the bodies of bac- 
teria. This is especially true of breast-fed infants. The 
normal infant stool contains no unchanged casein. 

Fat has an important influence upon the formation of 
the stool. On feeding with human milk poor in fat the 
stools are small, containing small quantities of solids and 
some mucus. On feeding with human milk which is rich 
in fat, normal stools are produced. Microscopically fat is 
always evident in stools, and is derived partly from food, 
and in small quantities from the secretion of intestinal 
juices. Fatty acids and fat soaps are constantly found. 

Salt excretion is an important function of the large 
intestine. In the breast fed, ash content of dry stool is 
10 per cent., bottle fed 40 per cent. Insoluble calcium 
salts harden the feces. 

The following are some tests on constituents of feces : 

1. Fat soap easily seen as fatty acid crystals (needles) 
by heating with acetic acid on the cover glass and allow- 
ing to cool. 



24 INFANT FEEDING. 

2. Carbofuchsin in weak solution stains as follows : 
Neutral fat : no stain. Soaps : faint rose color. Fatty 
acids : red. 

3. Sudan III. stains as follows: Neutral fat: orange 
red. Soaps : crystals do not stain. Fatty acids : stain 
red or crystals, orange red. 

4. Sugar is not demonstrable in any quantity as such, 
but the character of the fat soap stool seen in milk feed- 
ing without sugar is changed to a softer, smaller, and 
normal color by adding sugar. 

5. Starch is demonstrable by iodine test microscopic- 
ally, but care must be exercised in the interpretation of 
the test, as the starch may be derived from baby powders. 

The color of the stool is due to bile coloring matter de- 
rivatives: bilirubin and its reduction products, urobilin 
and urobilinogen. The smaller the reduction of coloring 
matter there is present, the more colored the stools. By 
marked reduction to urobilinogen, the color becomes al- 
most white. The more milk and cream, i.e., fat, in the 
diet, the paler the feces. The so-called soap stool is due 
to excess of fat and overfeeding with milk or cream, and 
is a firm, grayish, putty-like stool. (See Disturbed 
Metabolic Balance.) 

Thin watery stools must always be taken seriously. 
However, the same cannot be always said of green, curdy 
stools, which are not infrequently seen in thriving breast- 
fed infants. These curds are almost invariably due to 
fatty acids and soaps. 

Normal stools of breast-fed infants are homogeneous, 
salve-like, ochre-yellow color, acid, and of sour odor. 
Microscopically may be seen detritus masses, bacteria, 
few neutral fat corpuscles, and fatty acid crystals. 

Normal stools of bottle-fed infants vary with the diet. 



METABOLISM IN INFANTS. 25 

One can frequently tell the diet by the appearance of the 
stool. On milk diet : less frequent, usually 1 or 2 daily, 
firmer and drier, usually pale yellow, alkaline and of foul 
odor. Constipation is the rule in babies receiving large 
quantities of milk with a moderate amount of carbohy- 
drates. Sugars have a laxative tendency (fermentation). 
Excess of brown color may be caused by excesses of 
malt sugar. Starches, if well taken, tend to constipate, 
in large amounts they tend toward an acid reaction and 
an aromatic odor. 

Starvation of hunger stool is seen on a very limited 
diet, as minimum amounts of milk, tea, cereal water. 
The stool has a dark, greenish-brown color, is soft, and 
composed in great part of mucus, and appears semi-trans- 
parent. This mucus may lead to further starvation 
through mistaken interpretation of its meaning, and re- 
sult disastrously. 

In the past it was taught that a study of the stools gave 
one definite information for the differential diagnosis of 
the gastro-intestinal disease, but experience has taught us 
that conclusions are of value only when based upon stool 
examinations in conjunction with a careful study of the 
diet, and clinical examination of the infant. 

Urine. A normal infant urinates ten to fifteen times 
daily, and the urine passed represents 60 to 70 per cent, 
of the fluids taken as food and drink. It is acid in re- 
action, and should be free from albumin. However, al- 
bumin frequently is present in the simple nutritional dis- 
turbances, and almost constantly in severe acute illnesses. 
Temporary presence of albumin in the urine of the new- 
born may be considered physiological, as well as the uric 
acid during the very early stage. Great decreases, even 
to anuria, are common with the intestinal disturbances, 



CHAPTER IV. 

BACTERIA OF THE DIGESTIVE TRACT 
OF THE INFANT.* 

1. The Newborn. 

For about one day the meconium passed by the new- 
born baby is sterile. During this time, however, the bac- 
teria begin to invade the digestive canal of the infant 
through the mouth and through the anus. The initial in- 
testinal flora which thus develops is subject to marked 
differences, the number and nature of the bacteria de- 
pending chiefly upon the surroundings of the infant, and 
exhibits no characteristic constant findings. 

This period is followed by gradual transition in the 
nature and in the number of the intestinal bacteria, until 
about the third day after birth characteristic intestinal 
flora becomes established, consisting chiefly of Bacillus 
bifidus (in the nursing infant) and Bacillus coli (in the 
artificially fed infant), and, besides these, Bacillus acido- 
philus, Micrococcus ovalis, Bacillus lactis aerogenes and 
others. 

2. The Nursing Infant. 

The principal portal of entry of the intestinal bacteria 
is the mouth. There is no doubt that a great variety of 
organisms may from time to time enter this atrium, in- 
cluding not only the ordinary organisms of the nursling's 
environments, but pathogenic bacteria as well. A major- 
ity of these pass to the stomach, and they may pass to the 
intestinal tract. 



* In the elaboration of this chapter free use has been made of 
A. I. Kendall's Bacteriology, Lea & Febiger, Philadelphia and 
New York, 1916. 

(26) 



BACTERIA OF THE DIGESTIVE TRACT. 27 

The flora of the mouth and of the stomach are not 
well known, but they appear to be of relatively slight 
importance as a rule. 

The duodenal flora in health is composed chiefly of 
coccal forms of the Micrococcus ovalis type. Bacillus coli 
and other members of the colon. group are most numer- 
ous at the ileocecal valve and the cecum, and Bacillus 
bifidus or similar organisms dominate the large intes- 
tines from this level to the sigmoid flexure. The re- 
mainder of the large intestines to the rectum is some- 
what sparsely populated with living bacteria, partly be- 
cause the fecal mass is relatively desiccated by the ab- 
sorption of water, partly because of the accumulation of 
waste products of bacterial activity — principally acids re- 
sulting from fermentation of lactose, formed higher up 
in the tract — which inhibit the development of bacteria 
in the lower levels. 

Bacillus bifidus (Gram positive, blue stain) predomi- 
nates in the intestinal flora of the breast-fed infant, being 
acid tolerant and finding favorable conditions for its 
growth and development, since in digestion of mother's 
milk lactic acid production from lactose is so great as to 
inhibit the growth of the Bacillus coli and Bacillus lactis 
aerogenes in the lower end of the ileum, while the highly 
acid medium favors the growth of the Bacillus bifidus 
communis and the acidophile bacteria. Coccal forms and 
lactose fermenting organisms are present, but scanty; 
spore bearers are rare. 

3. Artificially Fed Infants. 

Escherich directed attention to the striking dissimilar- 
ity between the intestinal flora of the breast fed and the 
artificially fed infant. Culturally, morphologically, and 



28 INFANT FEEDING. 

chemically the former is more uniform than the latter. 
The most distinctive features of the dejecta of the arti- 
ficially fed infants are : the relative increase of Gram- 
negative bacteria of the coli-aerogenes type, and of coccal 
forms of the Micrococcus ovalis type, together with a 
diminution of Bacillus bifidus. Bacillus acidophilus is 
relatively more numerous, as a rule, in the artificially 
fed infant than in the nursling. Proteolytic bacteria of 
several types are also of frequent occurrence, but they 
are not commonly found in the dejecta of the normal 
nursling. These organisms are frequently spore-form- 
ing bacilli, of which two principal groups are recognized 
— members of the aerobic group, of which Bacillus mesen- 
tericus is a prominent type, and anaerobic bacteria, of 
which Bacillus aerogenes capsulatus is most widely 
known; it frequently occurs in small numbers in the 
feces of artificially fed infants. The reaction of normal 
feces of artificially fed babies is usually alkaline; cul- 
turally and chemically, the evidence of intestinal proteo- 
lysis of bacterial causation is more marked in these in- 
fants than in normal nurslings. 

The general distribution of types of bacteria at the 
different levels of the intestinal tract is similar to that 
observed in normal nurslings. The principal differences 
are found in the cecum and large intestine, where the 
obligately fermentative bacteria of the bifidus type are 
replaced to a considerable degree by an extension of 
habitat of the Bacillus coli, of Bacillus acidophilus, and 
the appearance of moderate numbers of proteolytic bac- 
teria, both aerobic and anaerobic; many of the latter are 
sporogenic. 

The characteristic feature of the normal adult fecal 
flora as compared with the infantile nursling flora is the 



BACTERIA OF THE DIGESTIVE TRACT. 29 

very heterogeneous variety of types of bacteria in the 
former, in sharp contrast to the homogeneity of types of 
bacteria in the latter. 

4. Significance of the Intestinal Bacteria. 

The striking differences in morphology, chemistry, and 
in cultural characters between the intestinal floras char- 
acteristic respectively of nurslings, artificially fed infants 
and adults suggest at once that nutritional stimuli may be 
.an important factor in determining the dominance of 
type of bacteria. It is probable that the significance of 
the intestinal flora lies rather in its potential antagonism 
to alien bacteria, which certainly gain entrance to the 
alimentary canal from time to time, than in any specific 
participation in the normal digestive process of the 
host. The normal intestinal flora may be regarded as intes- 
tinal parasites, just as the various bacteria which occur 
commonly on the skin are regarded as cutaneous para- 
sites. It is important to realize that the normal intestinal 
organisms, like the cutaneous organisms, are "oppor- 
tunists," potentially capable of becoming invasive when- 
ever the barriers which ordinarily suffice to limit their 
development to the lumen of the alimentary canal become 
impaired, giving rise to endogenous infections. 

5. Influence of the Diet on the Intestinal Flora. 

Intestinal flora varies greatly, the most important fac- 
tor in determining its nature being the chemical composi- 
tion of the food. Human milk gives essentially different 
flora from cow's milk. There are two groups of bacteria 
possessing an antagonistic action, those causing fermen- 
tation (saccharolytic), and those causing putrefaction 



30 • INFANT FEEDING. 

(proteolytic). The representatives of the former are Bac- 
illus lactis aerogenes and Bacillus bifidus, the latter being 
the most important organism in the stool of the breast-fed 
infants. The group exercising proteolytic activity is less 
clear. We know only that in the processes of putrefac- 
tion the bifidus flora is replaced by the coli group. De- 
pending on the predominating group of bacteria, putre- 
faction or fermentation takes place, causing either firm 
or soft stools, this rather than the activity of the ferments 
determining the nature of the stools. The nature of the 
food and its chemical composition, therefore, determines 
the nature of the development and activity of the par- 
ticular bacteria in the intestinal tract. 

The human milk, rich in sugar and low in protein, leads 
to the flora of fermentation, while cow's milk, rich in 
protein and poor in sugar, to the flora of putrefaction. 
This phenomenon is nothing specific, but is due to in- 
dividual components of the milk and their mixture. 

Carbohydrates lead to the development of the fermen- 
tative organisms ; the split products of carbohydrates are 
acetic, butyric, lactic and carbonic acids. 

The nature of the dominant organisms which develop 
in diets rich in carbohydrates varies with the carbohy- 
drate itself. Bacillus bifidus is more commonly predom- 
inant when lactose is the sugar fed, without an excess of 
protein. If maltose or dextrose is substituted for lactose 
under the same conditions, Bacillus acidophilus is very 
frequently the more prominent. 

The fermentative action is increased by sodium and 
potassium salts as found in whey. (This latter probably 
in part explains the results obtained in feeding malt 
sugars together with potassium carbonate.) 

Proteins favor the development of the organisms of 



BACTERIA OF THE DIGESTIVE TRACT. 31 

putrefaction and lead to formation of indol, skatol, and 
amino-acids, these being the products of aromatic and 
fatty series. Gases are also formed by the latter action. 

The nature of the protein influences the types of pro- 
teolytic bacteria to a very marked degree. In general, 
animal proteins other than casein appear to encourage 
somewhat more active proteolytic flora than vegetable 
proteins. The processes of putrefaction are favored by 
calcium salts. 

The influence of fat in its relation to bacterial proc- 
esses is not clear. It seems to be able to favor fermenta- 
tion, if this be already present, and also to increase the 
intensity of the processes of putrefaction. 

In breast feeding fermentation outweighs putrefaction. 
The question whether fermentation or putrefaction in 
the intestinal canal is desirable, must be answered a priori 
that the fermentative processes are physiological, since 
breast feeding always leads to this. By this it must not 
be understood that the putrefaction in artificial feeding 
causes injury. Excessive intestinal fermentation in ar- 
tificial feeding may be the forerunner of disaster, and is 
to be avoided (dyspepsia, intoxication). 

Within certain limits, we are able to influence the bac- 
terial processes in the intestinal tract in the normal infant, 
and thereby change the character of the feces. In a sick 
infant this is more difficult, and larger quantities of 
putrefacient food are necessary to overcome pathological 
fermentation. 

6. Intestinal Bacteria in Their Relation to Gastro- 
intestinal Disturbances. 

There are many intestinal disturbances of unknown 
causation, presumably unrelated to bacterial activity. 



32 INFANT FEEDING. 

There is a second group of conditions in which bacteria 
may conceivably play a secondary part; in some of the 
latter abnormal physiological conditions in the alimentary 
canal may be justly regarded as the antecedent factors. 
The boundaries of these two groups are poorly circum- 
scribed, and they merge through imperceptible or poorly 
defined limits into a third group of cases in which the 
activities of endogenous or exogenous bacteria in the 
alimentary canal may be the causative factor in morbid 
processes of the gastro-intestinal tract. 

The symptomatology induced from the products aris- 
ing from the decomposition of proteins or protein deriva- 
tives by the action of bacteria in the intestinal tract de- 
pends largely upon the organism or organisms concerned. 
It varies from the somewhat insidious, slowly progress- 
ing, so-called autointoxication, in which a marked in- 
crease of urinary ethereal sulphates may be a suggestive 
index, to the acute toxemias characteristic of bacillary 
dysentery, typhoid, paratyphoid or cholera. Of course, 
a variety of other bacteria than the few mentioned speci- 
fically may be concerned, either alone or in symbiosis. 
Thus streptococci alone, and streptococci in association 
with dysentery bacilli, may be justly regarded as the etiol- 
ogical agents in their respective syndromes. The im- 
portant factor, from the viewpoint of this discussion, is 
to realize that the formation of nitrogenous products 
from proteins or protein derivatives, which are being 
utilized by various types of intestinal bacteria for 
energy, may be injurious to the host. 

The other prominent type of abnormal bacterial activ- 
ity in the alimentary canal — the fermentative type — is of 
entirely different origin. The essential factor is either 
a fermentation of carbohydrates, with the formation of 



BACTERIA OF THE DIGESTIVE TRACT. 33 

products abnormal for the intestine, or of excess of nor- 
mal fermentative products. > The factors leading to an 
overgrowth of these organisms in the intestinal tract 
appear to be an excess of carbohydrate and a lack of 
normal lactic-acid-forming bacteria. 

It is unfortunate that practically none of the bacteria 
which incite intestinal disturbances or illnesses produce 
soluble toxins against which antitoxins can be prepared. 
Sera likewise have been unsatisfactory. There is little, 
therefore, that can be accomplished serologically with the 
present methods in the treatment of intestinal disturb- 
ances of bacterial causation. Attempts to permanently 
eliminate or destroy undesirable bacteria with cathartics 
and intestinal antiseptics have not been productive of re- 
sults in the past, and prolonged starvation per se does not 
lead to intestinal sterility or to a significant reduction in 
the offending bacteria. 

There are two ways, however, in which direct influ- 
ence may be applied to bacteria in the intestinal tract : 
by substituting harmless types of organisms for abnormal 
types, and by varying the diet of the host in such a man- 
ner that the intestinal contents at the desired level shall 
contain nutritive substances that may be reasonably ex- 
pected to shift the metabolism of the offending organism, 
and therefore radically change the character of the 
products of its metabolism. 

Diseases Due to Proteolytic Activity of Bacteria. 
There are a number of conditions of bacterial causation 
in which available evidence points strongly to the forma- 
tion of products arising from the metabolism of protein 
or protein derivatives by specific organism as important 
etiological factors in the morbid process. Thus, cholera, 
bacillary dysentery, typhoid, paratyphoid, and many less 

3 



'34 INFANT FEEDING. 

acute infections are associated definitely with the de- 
velopment of these organisms within the body, and to 
some degree at least, at the expense of the body tissues. 

Available evidence points strongly to the view that 
cholera vibrios, typhoid, dysentery and paratyphoid bacilli 
and similar organisms produce their characteristic and 
harmful effects when they are developing in media free 
from utilizable carbohydrates; when utilizable carbohy- 
drates are added to these media, non-characteristic, harm- 
less products are formed. 

In the absence of any definite indication to the con- 
trary, it would be logical to attempt to maintain a suffi- 
cient concentration of carbohydrates within the intestinal 
canal in these infections as a therapeutic measure. 

The important effects to be accomplished by a liberal 
carbohydrate diet in those infections where the decom- 
position of proteins or protein derivatives by bacterial 
activity leads to chronic or acute illness of intestinal 
origin are : a change in the metabolism of the offending 
organism resulting in the formation of lactic and other 
acids in them in place of putrefactive products, and a 
gradual replacement of the proteolytic and pathogenic 
types by bacteria of the fermentative varieties. 

Diseases Due to Excessive Fermentation of Carbohy- 
drates. Another type of intestinal disturbances depends 
upon an unusual or an excessive fermentation of carbo- 
hydrates. This is frequently seen in young infants, in 
many of whom we have a limited carbohydrate tolerance. 
(See Nutritional Disturbances.) 



Part II. 

The Nursing. 



CHAPTER I. 

GENERAL CONSIDERATIONS. 

Writers on this subject are very prone to state that 
the ability of the mother, particularly among the well-to- 
do, to fulfil this most important function is decreasing. 
This may have been a true statement fifteen or twenty 
years ago. At the present time, however, we are sure it 
is erroneous. The young mother of to-day is better able 
to nurse her offspring than was her sister fifteen or 
twenty years ago. We attribute this to the fact that the 
youth of the present day is more vigorous, more nearly 
normal individuals, than were those of an earlier date. 
Breast-milk during the first two or three weeks of the 
infant's life is produced under unfavorable conditions, 
which do not indicate the possiblities of the breast as a 
secreting organ. Early nursing, following as it does 
upon the stress of confinement, is not indicative of what 
may be possible later, when the customary life and daily 
habits are resumed. Repeatedly we have found a very 
high fat or a high protein, or both, entirely corrected 
after the first week or two without interference. This 
condition at the time was considered sufficiently serious 
to warrant the discontinuance of nursing on the part of 
a weakly infant, while in a vigorous infant it would be 
entirely ignored. A neurotic mother makes the poorest 

(35) 



36 INFANT FEEDING. 

possible milk-producer. Proportionate to the popula- 
tion, there are fewer neurasthenics among the young 
women to-day than there were twenty years ago, and 
there will be still fewer twenty years hence. At the 
present time the timid, retiring young woman of the 
neurasthenic type is not popular in her set. 

Few functions with which we have to deal are so 
variable and uncertain as the production of breast milk. 
Breast milk is one of the most precious substances. It 
is invaluable, unless we can put value on human life. 
The most successful nursing age is between the twentieth 
and thirty-fifth year. 

Some mothers will be able to carry on the nursing for 
only two months, others three, five, seven, or nine 
months. In our experience in both out-patient and in 
private practice it is extremely rare for the breast milk 
to be sufficient for the infant after the ninth month. 

It should be remembered that besides the protein, fat, 
carbohydrate, salts and water content there are other 
bodies contained in human milk, which, even though not 
essential to the infant's life, are of inestimable value 
to it. These may be divided into two groups : 

1. Immunizing bodies — antitoxins, alexins, etc. — 
which are contained in the mother's blood, and trans- 
mitted to the baby through her milk. They are of value 
in protecting the infant against infections. 

2. Ferments: lipase, galactase, lactokinase, and dias- 
tase. 

Examination of Human Milk. This is rarely of any 
practical value. The protein rarely causes trouble, and 
the sugar is usually constant (6 to 7 per cent.). The 
examination of milk is therefore usually restricted to a 
determination of the fat content by means of the lacto- 



GENERAL CONSIDERATIONS. 37 

meter. The richest milk, however, will usually agree 
with the baby, and it is apt to thrive equally well on a 
milk that shows a small amount of fat. In other words, 
the baby and not the lactometer is the only practical test. 
If the milk disagrees, it will be evident clinically. No 
baby should ever be deprived of its mother's milk only 
because of the results of a clinical examination of the 
milk. 

In making an examination of the mother's milk one 
must bear in mind that the first milk is very poor, the 
last very rich in fat, and that an average specimen can 
be obtained only by mixing the whole amount, or by 
combining the first and the last, or, better still, by taking 
only the middle portion after a few drams have been 
drawn off. This can be accomplished by allowing the in- 
fant to nurse for two minutes before expressing the 
sample. 

Contraindications to Nursing. Tuberculosis when 
progressive or open is always a contraindication to nurs- 
ing, because of the danger to the infant and the strain on 
the mother. With proper precautions, and where the 
breast is not diseased, and human milk is not obtainable 
from other sources, it may be well to tide a weak infant 
over its first weeks by expressing the milk from the 
mother's breast. 

Syphilis of the mother, except in freedom from infec- 
tion on the part of the infant, is not a contraindication. 
Lack of symptoms on the part of the mother in congeni- 
tal syphilis is a very common occurrence ; a Wassermann 
reaction on the mother's blood will quickly clear up any 
doubt. 

Any grave constitutional disease in which there is an 
extraordinary drain on the. resources of the body (dia- 



38 INFANT FEEDING. 

betes, heart disease with disturbed compensation, neph- 
ritis, Basedow's disease, malignant neoplasms, epilepsy 
and psychoses) are contraindications to nursing. 

Acute diseases should only in exceptional cases be con- 
sidered as contraindications to nursing, and should in- 
clude conditions in which there is danger of overburden- 
ing the mother and infections endangering the infant. 
(See p. 68 for further indications.) 



CHAPTER II. 
MATERNAL NURSING. 

1. Nursing Axioms. 

The following may be laid down as nursing axioms : 

A diet similar to what the mother was accustomed to 
before the advent of motherhood should be taken. 

There should be one bowel evacuation daily. 

From three to four hours daily should be spent in the 
open air in exercise which does not fatigue. 

At least eight hours out of every twenty-four should 
be given to sleep. 

There should be absolute regularity in nursing. 

There should be no worry and no excitement. 

The mother should be temperate in all things. 

/ 
2. Hygiene of the Mother. 

The Diet of the Mother. Many times, when con- 
sulted by nursing mothers because the nursing was un- 
successful or a partial failure, we have found that their 
diet had been restricted to an extreme degree. To put 
on a greatly restricted diet a robust young mother who 
has always eaten bountifully of a generous variety of 
foods is one of the best means of curtailing the quantity 
and lowering the quality of her milk supply. When 
asked to prescribe a diet, we tell such mothers to eat as 
they were accustomed to before the advent of pregnancy 
and motherhood. That this particular vegetable or that 
particular fruit should be forbidden on general prin- 
ciples is a fallacy. Food that the patient can digest with- 

(39) 



40 INFANT FEEDING. 

out inconvenience is a safe food so far as the nursing is 
concerned, as may readily be determined in any given 
case. For certain individuals, however, a plain, more or 
less restricted diet is desirable. This must be remem- 
bered in the management of the wet-nurse (to be de- 
tailed later). 

Nursing is a perfectly normal function, and a woman 
should be permitted to carry it out along the natural 
lines. Inasmuch as there are two lives to be provided 
for instead of one, more food, particularly of a liquid 
character, may be taken than the mother may be accus- 
tomed to. It is our custom to advise that milk be given 
freely. A glass of milk may be taken in the middle of 
the afternoon, and 8 ounces of milk with 8 ounces of 
oatmeal or cornmeal gruel at bedtime, if it does not dis- 
agree with the mother. Our only evidence that a food is 
disagreeing is the condition of the digestion. When 
any article of food disagrees with the mother, or if she 
is convinced that it disagrees, whether or not such be 
really the case, the food should be discontinued. In a 
general way, milk (one quart daily), eggs, meat, fish, 
poultry, cereals, fresh vegetables and fruits constitute a 
basis for selection. Although occasionally mother can- 
not take acid fruits, salads and aromatic vegetables, they 
may be tried and discarded, if they disturb the infant. 
Eggnogs, thin cereal gruels mixed with milk, cocoa and 
malted milk and similar drinks can often be taken to 
advantage between meals. 

The Bowel Function. A very important and often 
neglected matter in relation to nursing is the condition 
of the bowels. There must be one free evacuation daily. 
For the treatment of constipation in nursing women we 
have used different methods in many cases. The dietetic 



MATERNAL NURSING. 41 

treatment and plenty of recreation and exercise promise 
most. Manipulation of the diet should not be such as 
to interfere with the milk production. Three other 
methods are open to use: massage, local measures and 
drugs. Massage is available in comparatively few cases. 
Local measures consist in the use of enemas and sup- 
positories. Every nursing woman under our care is in- 
structed to use an enema at bedtime, if no evacuation of 
the bowels has taken place during the previous twenty- 
four hours. For a laxative in such cases and in many 
others, a capsule of the following composition has served 
well: 

I£ Extracti nucis vomicae 0.015 Gm. (J4 gr.). 

Extracti cascarse sagradse 0.325 Gm. (v gr.). 

Sig. : To be taken at bedtime. 

The amount of the cascara sagrada may be varied as 
the case may require. In not a few instances we have 
found it necessary to give 2 capsules a day in order to 
produce the desired result. Neither the nux vomica nor 
the cascara appears to have any appreciable effect on the 
child. 

Air and Exercise. Outdoor life and exercise are not 
only as desirable here as they are under all other con- 
ditions, but to the nursing woman, with her added re- 
sponsibility, they are doubly valuable. In order to get 
the best results, exercise or work should be so adjusted 
as not to reach the point of fatigue. The mother whose 
nights are disturbed should be given the benefit of a 
midday rest of an hour or two. It should be our duty, 
however, to explain to the mother and to other members 
of the family that an important element in satisfactory 
nursing is a tranquil mind. 



42 INFANT FEEDING. 

Care of the Breasts. A well established routine should 
be instituted for the care of the breasts. To facilitate 
this a readily accessible tray with the necessary utensils 
should be provided. This should contain a glass-stop- 
pered bottle with a saturated solution of boric acid, a 
jar of cotton pledgets on toothpicks, to be used as appli- 
cators for the boric acid, a graduated glass or beaker. 
The nipples should be thoroughly washed before and 
after nursing with a saturated solution of boric acid 
poured fresh from the bottle for each cleansing, and the 
surplus thrown away. The boric acid should be applied 
with the cotton pledgets. The fingers should not come 
in contact with the nipples, if the child is to nurse directly 
at the breast. If the nipples are tender, they should be 
annointed with a sterile mixture of 5 per cent, tincture 
of benzoin in liquid vaseline. 

All utensils, including the breast-pump, if one is in 
use, should be sterilized by boiling. In case of the breast- 
pump, the rubber bulb may be removed for this purpose. 
Where the milk is to be expressed by hand, the hands 
must be thoroughly disinfected by washing with soap 
and water, and rinsing with alcohol before manipulation 
of the breasts. Under all conditions soap and water 
should be freely accessible, and their use required before 
handling the breast or the infant. 

3. Conditions Influencing the Breast Milk. 

The advent of the first menstruation period particu- 
larly, and in some cases the beginning of every men- 
struation period, is attended with an attack of colic or 
indigestion in the child. Such attacks, however, rarely 
necessitate the discontinuance of the nursing even for 



MATERNAL NURSING. 43 

a single day. Not infrequently the quantity of milk is 
somewhat lessened during menstruation, and this will re- 
sult in the infant becoming fretful, due to insufficient 
quantity of the feeding. Under no circumstances should 
menstruation be considered an indication for weaning. 

Factors influencing the mental condition of the mother, 
such as anger, fright, worry, shock, distress, sorrow, or 
the witnessing of an accident may affect the milk secre- 
tion sufficiently to cause no little discomfort to the child, 
and oftentimes the lessening of the flow for a day or 
two. At times, especially when the mother is under in- 
fluence of shock or grief, it may be necessary to substi- 
tute artificial feeding for a few nursings during these 
periods, until the mother has again resumed her mental 
equilibrium, her breast being emptied by mechanical 
means in the meantime. 

Drugs, alkaloids of opium, hyoscyamiis, belladonna, 
and similar drugs, when given in large quantities, not in- 
frequently pass into the milk, and should therefore never 
be administered in large quantities to the nursing mother. 
Belladonna may cause a decrease in milk secretion, and 
should be administered with caution during the period of 
lactation. Mercury, iodides and the newer salts of ar- 
senic are also secreted in the milk, and may be used to 
advantage when a luetic mother is nursing a luetic infant. 

4. The Nursing Proper. 

Regularity in Nursing. The breast which is emptied 
at definite intervals invariably functionates better than 
does one which is not, not only as regards the quantity, 
but also the quality, of the milk, thus regular habits in 
breast-feeding are as essential to milk production as to 



44 INFANT FEEDING. 

its digestion and assimilation. The baby should be 
wakened to be fed. 

The average mother will supply the needs of the in- 
dividual meal with one breast, and the breasts should be 
alternated in successive feedings. Thorough emptying 
of the breast should be encouraged under all circum- 
stances, as this is our best method for increasing the 
milk supply, and the baby is the only means at hand by 
which this can be accomplished. This should be en- 
couraged in every instance. It is most readily thwarted 
by allowing a lazy baby to partially empty both breasts, 
and will soon lead to a diminished milk secretion. By 
this means the mother and the baby soon become adapted 
to one another, and it will be found that the desired effect 
is accomplished both where the milk supply is insuffi- 
cient or, again, excessive. In the former instance com- 
plete emptying of the breasts increases the secretion, and, 
where excessive, incomplete emptying will soon result in 
a lessened supply. 

Sometimes, however, it is advisable to give both breasts 
at each feeding, i.e., under the following conditions : ( 1 ) 
During the first few days, to stimulate secretion, and a 
little later to relieve the congested breasts; (2) to weak 
babies when there is an abundance of milk, and they are 
not strong enough to get the last milk that comes harder ; 
(3) to overfed babies, where it is desirable to give them 
only the first and weakest milk, and to lessen the yield 
of the milk from the breast ; (4) as the milk supplied by 
one breast fails to meet the needs of the infant, both 
breasts should be given at each nursing; the first breast 
should be thoroughly emptied before allowing the baby 
to take the second breast, and the next nursing started 
on the second breast given in the last feeding. 



MATERNAL NURSING. 45 

Number of Feedings in Twenty-four Hours. Four- 
hour intervals at start with six feedings in twenty-four 
hours, five feedings by the second to the fifth month, ac- 
cording to the individual needs of the child. Night 
nursing can often be discontinued by this time, and 
babies properly fed will go from 10 p.m. to 6 a.m. with- 
out anything but perhaps a drink of water. 

Premature and delicate infants and infants with a 
tendency to vomit are exceptions, and must be fed smaller 
amounts at more frequent intervals. 

Length of Nursing. As a rule, a robust baby takes 
three-fourths of the milk obtained from a good breast 
in the first five minutes of a twenty-minute nursing. 
Fifteen to twenty minutes should be the limit for the 
nursing period. If a baby is doing well on shorter 
periods, and seems satisfied, let it be its own judge of the 
nursing time. Weak and lazy babies may require 
awakening during the nursing period to keep them at 
work. Very weak babies may require a longer period, 
with short intervals, in which they rest. 

Giving of Water. From y 2 to 1 ounce of a 1 per cent, 
solution of cane or milk sugar should be given the infant 
every three or four hours until the milk appears in the 
breast. Otherwise there will be unnecessary loss of 
weight and perhaps a high degree of fever due to inani- 
tion. A high temperature during the first days of life is 
more commonly due to "inanition" than infection in 
present-day obstetrics. The best differential test is ad- 
ministration of water or sugar-water at regular intervals. 
In a case of inanition plenty of fluid intake results in a 
critical drop in the temperature. 

If the child is restless and uncomfortable, it is safe to 
conclude that it is thirsty. One ounce of the sugar-water 



46 INFANT FEEDING. 

will usually satisfy it. With the commencement of nurs- 
ing, the baby should be accustomed to getting the food 
at regular intervals. Even when milk is plentiful, the 
administration of water, two or three times daily, from a 
nursing bottle accustoms the baby to taking the food in 
this way. This makes weaning more easy in case of 
emergency. 



CHAPTER III. 
WET-NURSING. 

1. The Wet-nurse: Her Selection and Her Baby. 

The Problem. When there is a positive inability on the 
part of the mother to nurse her offspring, either through 
improper development on the part of the breast or sys- 
temic disease, we are confronted with the problem of 
securing human milk from another source, as notwith- 
standing the numerous reports on successful raising of 
infants on artificial foods, the statistics of infants fed by 
artificial foods when compared with those of infants fed 
on human milk are so strikingly in favor of the latter 
that the obtaining of human milk must always be con- 
sidered as an important issue. 

How Obtained. In our experience, even in a large 
city, great difficulty has been met in obtaining a regular 
supply of wet-nurses. On several occasions various 
charitable and hospital societies have attempted to estab- 
lish a wet-nurses' registry as a clearing-house for the 
several maternity and general hospitals of Chicago. 
These attempts have not been successful for two reasons : 
(1) because of the irregularity in the demand, and (2) 
because of the lack of co-operation on the part of the 
various institutions caring for this class of cases. 

The Nationality of the Wet-nurse is of considerable 
significance where the supply allows of a selection. The 
phlegmatic temperaments as seen in women of Northern 
and Central Europe of Teutonic and Slavic descent, 
offer the ideal material, while other nationalities, such as 
Italians, and the Southern negroes when removed from 

(47) 



48 INFANT FEEDING. 

their home environment to a Northern climate, secrete a 
milk poor in quality. However, even the latter in an 
emergency should not be neglected. 

Requirements of a Good Wet-nurse. 1. She should 
be in good health, and, especially, free from all con- 
tagious and infectious diseases, and also from local dis- 
eases of any kind, such as those involving the nose, 
throat, skin, etc. 

2. Her mammary glands should be of such quality that 
she can secrete sufficient milk of good quality, and the 
nipples sufficiently developed to allow of nursing, or 
proper expression of the milk. 

3. Whenever possible, her age should be not less than 
18 and not more than 35 years. 

4. The age of her baby, as compared with that of the 
baby she is to nurse, is a matter of indifference in most 
instances. However, the first weeks, or if possible the 
first two months, of lactation should be avoided, because 
of the presence of colostrum and the rapidly changing 
quality of the breast milk, which not infrequently causes 
serious gastric and intestinal disturbances in very suscep- 
tible infants, as evidenced by vomiting, colic and diar- 
rhea. Multiparity may be considered an asset, if the 
nurse has demonstrated her ability to care for and feed 
previous cases. A multipara is also less likely to be 
affected by her new surroundings, especially if this be a 
private home. When the wet-nurse has more or less 
direct charge of the infant, one who has been nursing 
her own or other infants will be more likely to meet the 
technical difficulties in the care of her charge. 

Examination of the Wet-nurse. The examination of 
the wet-nurse should always be made in a systematic 
manner to insure against overlooking important things. 



WET-NURSING. 49 

First, a careful history should be taken as to the num- 
ber of her children, miscarriages, and the presence of 
constitutional diseases in her family. 

Second, she should be thoroughly examined, all parts 
of the body being exposed, and the examination should 
include the skin and hairy parts of the body for the pres- 
ence of skin lesions and parasites, as well as for old 
luetic scars. The organs of the chest and abdomen 
should be subjected to careful examination. 

Third, the breasts should be examined. 

Fourth, the genitalia, including the cervix and the 
urethra, and in all cases a cervical (and where sus- 
picious, a urethral) smear should be taken and exam- 
ined for gonococci. As -a single smear is often mislead- 
ing, in cases of the slightest suspicion, where a girl baby 
is to be nursed, the examination of the cervical and 
urethral smears should be repeated. 

Fifth, an examination and search should be made for 
chronic infections, especially for syphilis. A Wasser- 
mann test should be made in every case, and reported 
upon before she is allowed to supply milk, as it is well 
known that a syphilitic mother in a very great number of 
cases shows no clinical evidence of syphilis. The 
mouth and pharynx, neck, anus and genitalia, entire skin 
and lymphatic glands should also be examined for evi- 
dence of syphilitic lesions. 

Tuberculosis. The lungs, glands, and osseous system 
should be examined, and a careful history as to suscep- 
tibility to colds and to recurring bronchitis elicited. 

Sixth. Acute infections. She should be questioned as 
to exposure to contagious disease, and she should be ex- 
amined for evidence of acute infections of the nose, 
throat, and ears. 

4 



50 INFANT FEEDING. 

Seventh. Her teeth should be examined and defects 
and pyorrhea corrected, if necessary, at the expense of 
the family. 

Eighth. The urine should be examined (1) for evi- 
dence of nephritis, (2) for evidence of diabetes. It 
should, however, be remembered that a positive reaction 
for sugar should not be overestimated, unless the sugar 
is proven to be dextrose, as very commonly in our ex- 
perience during the early weeks of lactation a lactosuria 
is present. The kind of sugar can easily be determined 
by the phenylhydrazine test, followed by a microscopical 
examination of the crystals. 

Ninth. Nervous and psychic disturbances, such as 
epilepsy, insanity, hysteria, should, if found, by all 
means exclude the subject. 

Tenth. Her child should be examined for evidence of 
syphilis. Possibly one of the best arguments for the 
non-employment of a wet-nurse during the first two 
months of her lactation is the possibility of a latent 
syphilis. Where there is the slightest doubt, a Wasser- 
mann reaction should be made on the infant. The gen- 
eral condition of the child gives us the best evidence both 
as to the quantity and to the quality of the maternal milk. 
Unless the source of the nurse be known, it is well 
to be certain that she is nursing her own baby. In case 
of its death or its absence, every effort should be 
made to obtain its condition at birth and its later 
development. 

So far as possible she should not be subjected to an- 
noying questioning on the part of the family, which is 
entirely unnecessary, if she has been properly examined 
by the physician. It has been our experience that such 
unnecessary questioning has led to nervousness, and not 



WET-NURSING. 51 

infrequently has caused her to decline the position, at a 
time when she was most needed. 

Her Place in the Household. She should be treated 
neither as a guest nor as a menial, but so far as possible 
should be graded according to her previous station in 
life. There is a grave danger of mental depression on the 
part of a woman, well-born and sensitive, who, through 
misfortune or necessity, is forced to seek this means of 
employment, and also of an exaggerated estimate of 
self-importance on the part of a woman but little accus- 
tomed to the luxuries of life upon her entrance into the 
home of employment, particularly if attentions are paid 
to her. As has been previously stated, all instructions 
and demands should be made by the person best qualified 
in the individual case. A divided responsibility will 
always lead to future complications. 

Her quarters should be well located ; their ventila- 
tion should be supervised, and she should be held re- 
sponsible for their general cleanliness. The wet-nurse's 
baby should always be kept in the room with her, so that 
she may feel the full responsibility for its health and care. 

The Quantity of Milk to be Expected from a Good 
Wet-nurse. The quantity and quality of milk supplied 
must vary greatly with the glandular development of the 
individual wet-nurse, the state of her health, and the 
factors quoted elsewhere which would affect it tempor- 
arily. The amount and variety of stimulation applied to 
the breasts, of which the direct nursing by a full-term 
infant is the most valuable (at least for the purpose of 
stripping the breasts), must be given due consideration. 
In view of the many emergencies and influencing factors, 
no absolute standard for quantity and quality can be set 
for general rule. 



52 INFANT FEEDING. 

A wet-nurse who does not secrete sufficient milk dur- 
ing the first few days in her new employment should not 
be discharged until every effort has been made to im- 
prove her milk production. Frequently the change in 
environment is sufficient to reduce it temporarily. 

Cost of Milk. The wet-nurses in Sarah Morris Hos- 
pital receive their board and room and $8.00 per week. 
Figuring the former at $5.00 per week, this would total 
a cost to the institution of $13.00 per week for each 
nurse. With an average of 30 to 40 ounces of milk per 
nurse daily, or 210 to 300 ounces per week, the average 
cost will be about 4.25 to 6.5 cents per ounce, or approxi- 
mately $1.35 to $2.00 per quart. 

When milk is dispensed to patients outside of the hos- 
pital, a charge of 10 cents an ounce is made for it, which 
is a reasonable price when all of the contending factors 
are taken into consideration. 

Number of Nurses Needed. Each good wet-nurse 
can care for the needs of about two infants, depending 
upon their weight and development. 

Length of Lactation. No time-limit is placed upon 
the employment of a wet-nurse as long as the quality and 
quantity of her milk is sustained, and she continues in 
good health. One of our nurses has an infant now thir- 
teen months old. Such long periods of lactation, how- 
ever, as a whole are not to be advised. 

The Wet-nurse's Baby. The presence of the wet- 
nurse's baby predisposes to her peace of mind, and 
wherever possible, she should take it with her. Her 
baby's state of health is by all means the best indication 
as to her ability as a nurse, and, with this, the presence 
of constitutional disease in herself. It may be of im- 
mense value, if the baby is strong and healthy, to keep 



WET-NURSING. 53 

up the flow of milk, in case the baby to be nursed is a 
weakling. It may also be used to estimate the functional 
capacity of a wet-nurse by nursing at regular intervals, 
and weighing before and after the nursing for twenty- 
four-hour periods. If in perfect health, it may be put to 
the breast, after the weakling has taken such milk as it 
has strength to draw. If this is not practicable, then the 
weakling should be nursed alternately with the well baby 
on each breast. It is also of immense value in emptying 
the breast after the wet-nurse has removed as much 
milk as it is possible by expression or by the breast- 
pump, if this is the means of drawing the milk for the 
weakling. It is a well-known fact in all institutions 
where wet-nurses are used, that the greater the degree 
to which the breasts are stimulated by suckling infants, . 
the greater will be the reward in production. If the milk 
is insufficient for both babies, partial or entire meals of 
artificial food may be substituted for the wet-nurse's 
infant. 

At the first sign of an acute illness on the part of the 
wet-nurse's baby, it should be separated entirely from the 
other baby, and removed from the breast; its illness 
should be given the same serious consideration as that of 
the other infant, so that the mother's anxiety may be re- 
lieved. It should receive as much of its mother's milk 
as can be spared. This can be expressed from the 
breasts and fed from a bottle. 

Feeding of the Wet-nurse's Baby. When a single 
infant is to be nursed, the second baby is often a neces- 
sity in the promotion of the development and stimulation 
of her breasts. No breast can be developed to its fullest 
capacity with the breast-pump or hand expressions. It 
is a well-known fact that the breasts will respond in pro- 



54 INFANT FEEDING. 

portion to the demand placed upon them, and in most 
instances during the first few weeks of the premature's 
life, when its demands are met by from 4 to 16 ounces of 
milk, the wet-nurse can supply sufficient milk for both 
babies. When her supply becomes insufficient to meet 
the demands, her baby can be put upon partial bottle 
feedings of the strength as indicated by its age and de- 
velopment. The progress of the wet-nurse's baby has 
great influence on her peace of mind, which may spell 
success or failure in her ability to carry out her work. 
When the premature infant gives evidence of sufficient 
strength to be placed upon the breast, we have found the 
application of the wet-nurse's baby to the other breast a 
very valuable expedient in aiding the flow of milk into 
the breast which is to be nursed by the weakling. In 
many instances we have seen the milk flow from the 
second breast by this method so freely that but very little 
effort was required on the part of the weakling to obtain 
its food. 

2. The Hygiene of the Wet-nurse. 

In general, everything that has been said in the chap- 
ter on hygiene of the nursing mother applies also to the 
wet-nurse — of course, with the proper modifications, 
made necessary by peculiarities of her position. 

Her clothes should be simple, and in every part 
washable. As the care of her undergarments is of even 
greater importance than her outer clothing, it is well that 
her laundry should be done with the family work, so that 
the family laundress who is trusted by the family may be 
charged with its inspection. 

To simplify nursing or the drawing of milk, the 
author has devised two garments for wet-nurses. The 



WET-NURSING. 55 

material used for the outer garment is of yellow gingham, 
such as is used in the making of hospital uniforms, the 
yellow color being selected to distinguish the wet-nurse 
from the blue, as used by the nursing corps. The cor- 
set-waist is to be made of heavy muslin. The corset, if 
worn at all, should be of a very low type, so as to avoid 
all pressure on the breasts. It is best of a cheap quality, 
so that it can be replaced frequently for sanitary reasons. 
Each wet-nurse should be supplied with four uniforms 
and six nursing corset-waists. 

The Diet of the Wet-nurse. There is danger of the 
creation of indolent habits through neglect of regular 
exercise and the lack of regular household duties, but 
even greater danger lies in the direction of overfeeding 
with unusual foods. The average wet-nurse is either ob- 
tained from an institution or a home in which the lux- 
uries of life are limited, and she has been accustomed to 
a simple nutritious diet. Every attempt should be made 
to supply the nursing woman with a well-rounded diet 
of simple foods, with milk and cereals as the basis, and 
these supplemented with meats, soups, the common vege- 
tables, limited amounts of fruits and plain desserts. In 
so far as possible, the aromatic vegetables, unripe and 
highly acid fruits, fried meats, and rich pastries are to be 
avoided. We believe that, on the whole, too great stress 
has been laid upon the danger of the diet in the mother 
of a full-term infant, and in most cases the average 
mother can partake of a very full diet. However, in the 
case of the woman nursing premature infants, it should 
become a custom to allow only such foods during the 
first few days after her installation as can be given with 
perfect impunity. When a full, free flow of milk is 
established, other vegetables and fruits can be added. 



56 INFANT FEEDING. 

one at a time, and after each addition to the diet a try- 
out should be given the milk. We have on numerous 
occasions seen marked intestinal distention and diarrheal 
attacks following even seemingly slight indiscretions of 
the diet on the part of the wet-nurse. It is our hospital 
practice to furnish each wet-nurse with two quarts of 
good wholesome milk daily, and at least one pint of 
cereal gruel, preferably farina or corn-meal. A mixture 
of milk and cereal gruels makes a very good combination 
for drinking midway between meals. The remainder of 
the milk may be taken with the meals, either pure or in 
the form of cocoa, tea, or weak coffee, in whichever form 
it is best taken by the individual woman. The latter is of 
considerable importance, as in the forced diets which are 
required, where an abundance of milk is demanded, dis- 
tasteful foods soon become obnoxious in large quan- 
tities. 

Beers, malt-extracts, and other rich drinks are not 
forced upon the nurse, unless she is accustomed to them, 
and feels their need. It must always be remembered that 
an excess of fluids would naturally tend to dilute the 
milk unless the secreting gland be of exceptional develop- 
ment. 

Exercise of the Wet-nurse and Her Work. She 
should be impressed before her engagement with the fact 
that she will be required to do a moderate amount of 
work and exercise regularly out of doors. The former 
will be of service in promoting her general health, and 
both the work and the exercise will serve as a nerve tonic 
and prevent her becoming indolent. This does not mean 
that she should become a drudge, but that she should at 
least be required to care for her own room and her own 
infant's clothes, and should be made to feel that in re- 



WET-NURSING. 57 

turn for her laundry work she would be requested to do 
some light general work about the house. Her exercise 
in the open air should so far as possible be at regular 
times. The question as to the care of the napkins of both 
babies is open to considerable discussion; and it may be 
stated that whenever it becomes necessary for the nurse 
to express her milk by hand, she should not be subjected 
to the handling of soiled napkins, whenever this can be 
averted. 

Other Conditions Influencing the Quality 
of the Breast Milk. 

The nervous and mental state of the nurse is of the 
utmost importance, and wherever possible an emotional, 
nervous, erratic woman should be excluded, because of 
the tendency of these influences to suppress the flow of 
milk. Therefore, whenever possible, a woman of more 
or less phlegmatic temperament is to be selected. This 
is especially true in the case of a woman who is to be 
in close contact with and is to nurse an infant with neu- 
rotic tendencies. There is also the possibility of the same 
influence being manifest in time of slight indisposition 
on the part of her own infant^ and such an individual is 
also more likely to resent the necessity of partial or en- 
tire artificial feeding of her own child to the advantage of 
the premature infant, when it has reached such an age 
when it may make greater demands on her supply. 

Menstruation rarely produces any serious disturb- 
ances. It is always a safe procedure to dilute the milk 
during the first and the second day of menstruation when 
the nurse suffers considerable pain at these times. 

Period of lactation may or may not be a considerable 
factor, depending upon the individual woman. At the 



58 INFANT FEEDING. 

present writing we have in our employ a nurse who hc^s 
been with the institution for sixteen and a half months, 
and whose infant is eighteen months old, and who is sup- 
plying us with the largest quantity and the best quality of 
milk of the four nurses in the institution.* When possible 
a nurse should be selected after the first few weeks of 
lactation, at which time the colostrum has disappeared 
from the milk, and the quantity and quality of her milk 
has become established. After the first few weeks of lac- 
tation, but little or no attention is to be paid to the age 
of the wet-nurse's baby as compared with that of the 
infant to be fed, and we have never noted any ill effects 
following this rule. 

3. The Nursing. 

The Infant's Bedroom. Under ideal circumstances, 
this should be separated from that of the wet-nurse. 
This is especially true where a trained attendant has care 
of the infant. It should under all circumstances also be 
separated from the wet-nurse when she is of a low de- 
gree of intelligence and of a type not to be trusted with 
the care of the infant. 



* The milk of this nurse was examined in the laboratories of 
the University of Chicago after seventeen months of lactation 
with the following result : 

Protein 1.98 per cent. 

Casein 0.69 

Fat 3.54 " " 

Lactose 7.025 " . " 

Salts 0.1885 " " 

It must be remembered that this is an exceptional case, and but 
few women under the stress of ordinary life can properly nurse 
their infants after the ninth to twelfth month. 



WET-NURSING. 



59 



Methods of Drawing Milk. Numerous methods of 
obtaining milk from the breasts have been described, but 
only those most practicable of application will be de- 
tailed. These should be divided, first, into those in which 
the baby is placed directly at the breast, and those meth- 




Fig. 1. — Proper method of holding baby during nursing. 

ods by which the milk is drawn from the breasts and fed 
to the infant. Two methods are especially applicable 
where the baby is fed directly on the breast, and needs 
assistance because of its weakness. 

1. Premature infant is placed at the breast, and is 
supported there by the nurse's right arm while nursing at 
the right breast, and the left hand is used to grasp the 
breast just above the nipple between two fingers (see 



60 



INFANT FEEDING. 



p. 59), and the milk is expressed directly into the baby's 
mouth. In this way the baby is taught to take the breast, 
and at the same time receives its food with little effort. 
This method can be continued until the baby has gained 
sufficient strength to nurse without assistance. 

2. Much of the same result can be accomplished by 
placing the wet-nurse's baby on the opposite breast dur- 
ing the nursing period, whereupon the simultaneous nurs- 



■ -0 J . . , 


" 


itT^Z^z 


^|r K In 


■■ k ■■■n^^**^ 


f 


\"1^ ;;.;.. : p : 


«w.w *$»* 


l ^M 



Fig. 2. — Author's improved breast milk collector. The 
pump is made in two types, the first filled with a large rub- 
ber bulb of a size considerably larger than is ordinarily 
sold with a breast-pump, and the second with an attach- 
ment to which the Holz vacuum pump can be fitted. In 
place of the ordinary collecting bulb at the lower surface, 
an arm is so constructed as to allow the milk to drain into 
specially designed graduated 2-ounce milk flasks. 

ing on both breasts will cause a free flow of milk into 
both sides. 

In those methods by which the milk is drawn from the 
breasts and fed to the infant by hand or by other means. 

1. By the breast-pump. The modification of Holz 
vacuum apparatus, as devised by the author, by which 



WET-NURSING. 



61 



means the milk is drawn directly into two graduated 2- 
ounce flasks, which can be rilled to the quantity desired, 
and stoppered for future use, so that the milk is free 
from handling, and thereby avoid contamination. 




Fig. 3. — Direct expression of milk (act 1). Glass grad- 
uate is held against breast one inch to one inch and a-half 
back of the nipple, and held in position by the bent fore- 
finger of the left hand. Thq left thumb gently grasps the 
upper part of the breast about one inch behind the nipple. 
The thumb of the left hand gently compresses the breast 
against the side of the glass with a gentle sweeping move- 
ment. This is repeated 40 to 60 times per minute. 



2. By direct expression, which is performed as fol- 
lows : A graduated glass is held against the underside of 



62 



INFANT FEEDING. 



the lower inch of the breast and nipple by the index and 
middle finger and a downward sweeping stroke is used to 
compress the corresponding part of the breast and the 
nipple against the side of the glass receptacle. The ves- 
sel can be supported with the other hand. (Many nurses 




Fig. 4. — Direct expression of milk (act 2). 



prefer to make expression by compressing the breast 
between the thumb and forefinger omitting the use of 
the graduated glass, using the same sweeping motion.) 
By this means, following a little practice, the nurse can 
express from 6 to 8 ounces of milk from two good breasts 
in fifteen to twenty minutes. While drawing, each 2 
ounces of milk is poured directly into sterile, stoppered 



WET-NURSING. 63 

bottles, to prevent the fingers of the nurse coming in 
contact with the milk by overfilling the glass. It goes 
without saying that before each expression the breasts 
must be thoroughly cleansed with a boric acid solution, 
and the hands thoroughly washed with soap and water. 

Daily Number of Expressions. Expression is per- 
formed six times daily at regular intervals of four hours 
during the day and night. 



CHAPTER IV. 
THE NURSING INFANT. 

Signs of Successful Nursing. The normal full-term 
infant shows a gain of not less than 4 ounces weekly. 
This is the minimum weekly gain which may safely be 
allowed. When a nursing baby remains stationary in 
weight or makes a gain of but 2 or 3 ounces a week, it 
means that something is wrong, and the defect will usu- 
ally, but not invariably, be found in the milk supply. 
When the baby is nursed at proper intervals, and the 
supply of milk is ample and of good quality, it is satis- 
fied at the completion of the nursing. Under three 
months of age it falls asleep after ten or twenty minutes 
at the breast. When nursing period again approaches, it 
becomes restless and unhappy, crying lustily if the nurs- 
ing be delayed. When the breast is offered, it takes it 
greedily. The weekly gain in weight under such condi- 
tions is usually from 4 to 8 ounces. At the fifth month 
the baby will have doubled, and at the twelfth month 
trebled its birth weight. The average gain per week dur- 
ing the first year is about 4 ounces. 

The baby increases in length from about 20.5 inches 
(50 cm.) to 28.5 inches (70 cm.) in the first year. The 
first tooth appears at about the sixth or seventh month, 
and at one year there should be six teeth or more. (Age 
in months minus 6 = number of teeth normally present 
at that age.) It begins to smile at about the fifth week, 
grasps objects and holds its head erect in the fourth 
month, sits alone for a few minutes at seven or eight 
months, bears its weight on its feet at the ninth or tenth 
(64) 



THE NURSING INFANT. 65 

month, stands with slight assistance at the eleventh or 
twelfth month, and creeps or walks soon after this (tenth 
to eighteenth month, average fourteenth month), and 
says a few words towards the end of the first year. 

Stools.. The feces of breast-fed babies are strikingly 
uniform, and are like no other bowel movement in in- 
fancy. Normally, there are two or three a day, some 
times only one, or even more than three. They are soft, 
or mushy, homogeneous, of an egg-yellow or gold color, 
and have a slightly sour, not at all unpleasant odor. They 
are never formed, and always cling to the diaper. The 
nature of the bowel movement, and its uniformity, is due 
to the "physiological fecal flora" which is brought about 
by the ingestion of breast milk into the germ-laden in- 
testinal tract, and which in turn have a fermentative 
rather than a putrefactive action on the food. The gases 
normally formed are carbon dioxide and hydrogen, and 
these are practically odorless. The acidity of the move- 
ment, its softness, and the mechanical action of the gases 
present, all insure active peristalsis and ready emptying 
of the bowels, so that constipation is an exceptional con- 
dition in a breast-fed baby, and, if present, it nearly al- 
ways suggests too little food, or abdominal and intestinal 
muscles too little developed and too weak to force the 
stool past the anal sphincter. This latter condition is 
commonly interpreted as constipation by the laity. 

The dried residue of the feces contains from 10 to 30 
per cent, of fat, about 8 per cent, salts, a very large per- 
centage of bacteria, bile pigments, intestinal secretion 
(mucus, etc.), epithelial cells, etc. No food proteins or 
carbohydrates are found. 

The feces of the breast-fed baby are very frequently 
not wholly normal ; they quite commonly, especially dur- 



66 INFANT FEEDING. 

ing the first few months, contain small, soft, white or 
yellowish fat curds, an excess of mucus, and are often 
greenish in color, and may be more frequent than nor- 
mal. Such a condition is perfectly consistent with a nor- 
mal growth and well-being of the baby, and should never 
in itself be a cause of worry, or an indication for a 
change of food. This is a very important point that is 
very commonly neglected. The condition of the bowel 
movements is only one factor, and in the breast fed a 
minor one, in determining a baby's nutrition. 



CHAPTER V. 

MIXED FEEDING AND WEANING. 

Mixed Feeding (allaitement mixte). With a dimi- 
nution in the amount of milk secreted, the breast milk 
must, of course, be complemented or supplemented by 
modified cow's milk. These methods of feeding are usu- 
ally successful. By complemented feeding we mean the 
administration of milk from a bottle following a period at 
the breast at each nursing. By supplemental feeding sub- 
stitution of a bottle for a breast feeding is meant. Thus, 
in the former the baby receives as many part bottle as 
breast feedings, while in the latter it will be supplied with 
one or more bottle feedings to replace breast feedings. 
As we know that the breast secretes in proportion to its 
stimulation, the complementary feeding is far more satis- 
factory, and not infrequently it is wise to nurse both 
breasts for a short time, let us say, each one three to 
five minutes, before the bottle is giyen. The infant 
should then be weighed before giving the bottle to 
ascertain the amount of complemental feeding needed. 
The modified milk strength should be that which is 
suitable for the average child of the same age (see Arti- 
ficial Feeding). In beginning the use of cow's milk, 
however, it must be remembered that at first a weaker 
strength must be used than the child will require for 
growth, this weaker food being necessary in order 
gradually to accustom the infant to the change. If too 
strong a cow's milk mixture is given at first, it will be 
very apt to disagree, causing colic and vomiting. Later, 
when the child has become accustomed to the new food, 
a stronger mixture may be given. When a mother can- 
not give her infant at least two satisfactory breast feed- 
ings daily, it is advisable to wean the child. The new- 

(67) 



68 INFANT FEEDING. 

born baby is not very discriminating, and will nurse 
anything equally well. The older baby, however, quickly 
prefers the easy-flowing bottle to the increasingly un- 
satisfactory breast, and will quite regularly stop nursing 
at the breast as the milk comes harder and is less abun- 
dant. If the bottle is given right after the breast, it is 
always well to use a nipple from which the milk comes 
with some difficulty, for the reasons given above. If it 
is desirable to wean the baby rather quickly, this method 
of following the breast by the bottle is often to be 
preferred to the other. 

Indications for Weaning. Pregnancy is usually an 
indication for weaning. The mother's milk becomes 
more scanty, and often poor in quality. This is especially 
the case if the mother knows she is pregnant, and has 
been taught that a pregnant woman should never nurse a 
baby. If the baby continues to thrive at the breast, there 
is no reason why nursing should not be prolonged. For- 
tunately a new pregnancy does not often supervene be- 
fore a time that makes it quite safe to wean the nursing 
baby, i.e., before the sixth month. 

In acute infections in the mother, such as pneumonia, 
and the acute contagious diseases, such as scarlet fever, 
one must weigh the danger from exposure to infection as 
against the quality of the artificial food and environ- 
ment in the individual case. 

In the milder contagious diseases, such as measles, 
mumps, it is true that young breast-fed infants are rarely 
infected. Pertussis is an exception, and has a high mor- 
tality in the newborn and young infants; and the infant 
should under all circumstances be protected from ex- 
posure. In the presence of diphtheria the infant can be 
immunized with safety. 



MIXED FEEDING AND WEANING. 69 

Weaning should always be done gradually, when pos- 
sible, for the sake of both mother and the child. In 
cases of sudden weaning, the food must be very much 
weaker in the beginning than for an artificially fed child 
of the same age. If weaned at six months, the infant 
should be put on a mixture suitable for a child of two or 
three months, and the same rule applies for older infants. 
When the infant becomes accustomed to cow's milk, the 
strength can gradually be increased. Rarely should 
breast feeding be continued beyond the first year. 

The fear of the laity of the "second summer" is well 
founded when dirty milk and other improper foods are 
fed promiscuously, but with clean, certified, and sterilized 
milk, and properly prepared soft foods, the dangers of 
the summer heat are minimized. It should be our rule 
to underfeed rather than overfeed in hot weather, and 
during the hot spells the infant's diet may well be re- 
duced one-half. 

Care of the Breasts During Weaning. When the 
breast feeding is carried on the usual length of time 
(from nine to twelve months), the process of weaning 
ordinarily causes little or no discomfort. All that is usu- 
ally required is to press out enough of the milk to re- 
lieve the patient as often as the breast becomes painful, 
which may not be more than two or three times a day. 
When the weaning is necessarily abrupt, no little dis- 
comfort may result. When the weaning can be accom- 
plished more gradually, the infant should have one less 
nursing every second or third day, until only two are 
given daily. After this has been practised for one week, 
nursing should be discontinued. In cases of sudden 
weaning, a saline laxative, such as citrate of magnesia or 
Rochelle salts, should be given every day for five days — 



70 INFANT FEEDING. 

sufficient to produce two or three watery evacuations 
daily. In the meantime the mother should abstain from 
fluids of all kinds up to the point of positive discomfort. 
The breasts should be elevated by a firm binder. 



CHAPTER VI. 

NUTRITIONAL DISTURBANCES IN THE 
BREAST-FED INFANT. 

Breast milk alone furnishes all of the needs for 
growth and development of the human offspring. The 
infant will thrive in most instances on breast milk from 
different sources and different quality, demonstrating the 
ability of the average infant to assimilate the food which 
Nature intended for its use, even though the percentage 
quantity of the various components may vary greatly. 
Disturbances in the breast-fed baby are dependent upon 
one or more of several factors. In the order of their fre- 
quency they may be divided, as follows. 

1. Underfeeding. 

2. Overfeeding. 

3. Congenital debility, with resulting impairment of 
the vital functions. 

4. Intercurrent parenteral (pharyngitis, tonsillitis, 
bronchitis, pneumonia, pyelitis, etc.) and enteral in- 
fections. 

5*. Idiosyncrasy towards mother's milk. 

While all nutritional disturbances in young infants are 
of serious import, they are far less dangerous than those 
of the artificially fed infant, and much more easily cor- 
rected. They are also much less frequent than nutritional 
disturbances in artificially fed infants. 

1. Underfeeding. 

Etiology. Two factors of prime importance must 
be investigated to complete the diagnosis : 

(71) 



72 INFANT FEEDING. 

(1) The daily quantity of the milk furnished to the 

infant. 

(2) The quality of the milk supplied by the mother. 
The milk may contain the normal percentage of fat, 

sugar, and protein, but be scanty in amount. Instead of 
the 4 or 5 ounces to which the child is entitled, it may 
get but 1 or 2 ounces. Whether or not the quantity is 
sufficient, may be determined by weighing the baby be- 
fore and after each nursing for twenty- four hours. 
(The ordinary spring balance infant scale will not 
answer, and a simple beam scale with weights and scoop 
should be supplied.) One ounce of breast milk weighs 
practically 1 ounce avoirdupois. By nursing for fifteen 
minutes, a child under one week old should gain 1 to 1.5 
ounces; at three weeks of age, 1.5 to 2 ounces; four to 
eight weeks of age, 2 to 3 ounces ; eight to sixteen weeks 
of age, 3 to 4 ounces ; sixteen to twenty-four weeks of 
age, 5 to 7 ounces; six to nine months of age, 6 to 8 
ounces; nine to twelve months of age, 8 to 9 ounces. Of 
course, arbitrary limits cannot be fixed as to the quan- 
tity. It is not necessary to worry about the quantity 
taken at individual feedings so long as the infant is mak- 
ing satisfactory gains in weight, and the general progress 
is good. 

Quantity of Human Milk Required by the Nursing 
Baby. Babies of the same age and weight, under the same 
conditions, will take nearly the same amount of food. The 
older and larger the baby, the larger the total quantity of 
food required, but its energy quotient — that is, the num- 
ber of calories per kilogram or a pound of weight — lessens 
steadily with increasing age. The daily amount that nor- 
mal, thriving babies take from the breast can be stated 
at about one-sixth to one-fifth of their body weight dur- 



NUTRITIONAL DISTURBANCES. 73 

ing the first month, about one-sixth to one-seventh up to 
the sixth month, and about one-eighth after the sixth 
month. Heubner expressed this in terms of energy 
quotient, as follows: "During the first few months an 
infant requires 100 calories per kilogram daily of breast 
milk ; after the sixth month this energy quotient gradually 
comes down to 80 or 85 at the end of the first year. An 
energy quotient of 70 is about the minimum amount that 
an infant can take without losing weight." Human milk 
can be estimated at 21 calories per ounce, and about 70 
calories per 100 Gm. of milk. With these figures in 
mind, it is easy to determine whether a breast-fed infant 
gets about the right amount of food, and we have also a 
valuable standard by which to measure the food of an 
artificially fed infant. 

Symptoms. Failure to gain weight properly,, or even 
a loss in weight, may be the first positive evidence of an 
insufficient food supply. Usually this is associated with 
more or less evidence of dissatisfaction on the part of the 
infant. The infant's sleep becomes disturbed, and it 
becomes restless, and cries long before the next feeding 
time. Again, it may manifest its dissatisfaction by nurs- 
ing greedily for a short time, releasing the breast and 
crying. It returns to the breast again, but with the same 
result ; or in other instances the infant will remain at the 
breast for much longer periods than should be necessary 
to obtain the food that it needs, which would be accom- 
plished in from ten to twenty minutes. 

Usually the stools are normal in appearance, but small 
in amount, and give little evidence of the cause of the 
trouble. However, if the food supply be decidedly in- 
sufficient, we may have a positive evidence of the under- 
feeding by the appearance of the so-called "hunger 



74 INFANT FEEDING. 

stools," which are of more or less brownish or greenish- 
brown color, containing little fecal matter and much 
mucus. 

If the condition is not corrected, the baby becomes 
weak and apathetic. The skin loses its turgor, its tem- 
perature becomes subnormal, it is pale and anemic, the 
fontanelles become depressed, and the abdomen sunken. 
Whenever there is room for doubt as to the cause of this 
group of symptoms, the scale will be the most positive 
evidence. 

Treatment. Undue haste in removing the baby from 
the breast offers the greatest danger in the treatment of 
underfeeding, and should be resorted to only when other 
means fail. The ability to increase the quantity of milk 
secreted by the average woman must necessarily vary 
directly with the quantity and quality of the glandular tis- 
sue composing the breast. However, to a certain extent 
at least, certain factors will more or less directly in- 
fluence the quantity and quality of the secretion, and they 
are worthy of our attention. 

Means of Stimulating the Breasts. The surroundings 
of the mother must predispose to a happy frame of mind ; 
she must not be overburdened with household cares ; her 
exercise must be regular, and she must be relieved of 
worry and lack of sleep. It is well, if possible, to free 
her from all care of the baby, especially at night. She 
should be put in as good physical condition as possible; 
she should get out of doors. 

Giving both breasts at each feeding and temporarily 
shortening the nursing periods to 3 or even 2 hours, 
thereby increasing the number of feedings, are the best 
stimulants available. 

Her appetite should be stimulated, so that she will take 



NUTRITIONAL DISTURBANCES. 75 

an abundance of milk and other nutritious food. The 
very common forced feeding beyond the natural appe- 
tite, is of questionable value. The general rules as to the 
diet previously spoken of should be maintained. It 
should, however, be remembered that an excessive diet 
may be assimilated by the mother's body without increas- 
ing the flow of milk. The fluids given should be palat- 
able to the nursing mother, and, as previously recom- 
mended, milk, weak tea, cocoa, farina, oatmeal, and corn- 
meal gruels as well as milk soups are probably the best. 
The fat and the protein of the milk can more especially 
be influenced by the diet. The fats are increased by over- 
feeding with fats and carbohydrates, with little or no 
exercise. They are reduced by limiting these articles and 
substituting vegetables, and by increasing the amount of 
exercise. The protein is also increased by overfeeding 
and limited exercise. The carbohydrates are less in- 
fluenced by the diet, but are also affected by an excess 
of carbohydrate feeding. Alcohol in the form of malted 
drinks has a temporary influence in increasing the quan- 
tity of milk and the amount of fat. The effect on the 
protein is less constant. We never force a woman to 
partake of alcoholic liquors unless she desires them, be- 
cause of the moral as well as of the physical effect. 

Stimulating massage may be applied to the breast in 
such a manner as to stimulate the whole gland. This 
can best be accomplished by two movements: (1) by 
gently raising the whole breast from the chest wall and 
kneading it gently between the fingers, and (2) by hold- 
ing the breast against one hand and making circular 
movements around the periphery with the outspread 
finger tips of the other hand, and gradually working from 
its base towards the nipple. 



76 INFANT FEEDING. 

Baths at a temperature comfortably cool (80° to 90° 
F.) should be taken daily to promote her general health 
as well as cleanliness. These should be followed by a 
brisk rubbing with a coarse towel. 

Steaming the breasts by the application of hot towels 
covered with oiled silk two or three times daily is of 
decided benefit. 

The Bier pump and other means of stimulating an arti- 
ficial hyperemia can be used to advantage in obstinate 
cases. The application should be made at regular inter- 
vals, and not too long continued. 

Galactagogues of any material value for permanent 
use are unknown. Pituitrin has been recommended for 
temporary stimulation. We have not had much experi- 
ence in its use. General tonic will often improve the 
digestion and tend to overcome the anemia, and in this 
way improve the general health, and thereby lactation. 

2. Overfeeding. 

This condition is a rare one in the breast-fed baby, 
and, when present, in all but the very young and pre- 
mature, nature often provides its own remedy, either by 
regurgitation on the part of the baby, or by its refusal to 
nurse longer than to meet its needs, which latter soon 
leads to a lessened, milk secretion. In the first weeks and 
months it may be of considerable importance, and may 
cause grave symptoms on the part of the infant — that is, 
before the mother's breast and the infant have become 
adapted to one another. 

Etiology. Although overfeeding in the breast-fed 
infant is rare when compared- with overfeeding on arti- 
ficial food, yet next to underfeeding it is the most com- 
mon form of nutritional disturbance in the breast-fed 
> 



NUTRITIONAL DISTURBANCES. 77 

infant. It is also more commonly present in infants fed 
by a wet-nurse than in infants nursing the maternal 
breast. 

Usually the error lies in too frequent nursing. 

Rarely it may be due to excessive quantities of milk 
taken at proper intervals. 

Occasionally it is due to milk which is excessively rich 
in fat. 

Pathogenesis. The normal infant's stomach on 
breast feeding empties itself in about two hours. When 
all the food has left the stomach, and is undergoing intes- 
tinal digestion, free hydrochloric acid is forming in the 
stomach. Free hydrochloric acid is antiseptic, and it also 
stimulates secretion of pancreatic juice and secretion of 
bile, both of the latter products being essential to proper 
intestinal digestion. 

For normal digestion it is therefore necessary that the 
stomach remain empty for some time after all the food 
has left it. When by too frequent nursings no time is 
allowed for the above described physiological process, or 
when by excessive quantities of food at proper intervals 
too great demands are made upon the hydrochloric acid, 
and the time of gastric digestion lengthened, with cor- 
responding shortening of the period of comparative rest, 
or the gastric secretion diminished by excessive fat, then 
we may expect disturbance of the normal digestion due 
to overfeeding. 

Symptoms. The earliest symptoms are regurgita- 
tion, diarrhea, and lessened appetite. These three symp- 
toms are reactions of the organism to excessive intake of 
food attempting to get rid of the excess. 

Regurgitation occurs at first occasionally only, imme- 
diately after nursing, and without any discomfort on the 



78 INFANT FEEDING. 

part of the infant ("spitting"). The regurgitated fluid 
is often unchanged milk. This is usually the first pre- 
monitory symptom. 

Diarrhea follows when overfeeding continues and re- 
gurgitation becomes insufficient to rid the body of excess 
of food. The stools are more frequent than normal, and 
contain undigested particles of food. 

Lessened appetite, although present in many cases, 
may be replaced by symptoms suggestive of hunger, the 
infant taking the breast and nursing greedily. This ap- 
parent symptom of underfeeding and of hunger may 
wrongly be interpreted, and lead to additional overfeed- 
ing by giving the breast at even more frequent intervals 
to allay the apparent hunger and to quiet the restless 
infant. 

In many cases no other symptoms develop, the condi- 
tion undergoing a spontaneous cure. The breasts lessen 
their yield, and thus the cause of the condition disap- 
pears, or, on the other hand, the digestive power of the 
infant increases to such an extent as to be able to take 
care of the excess, if not too large. This accounts for the 
fact that frequently the above-named symptoms are 
neglected, since they usually produce improvement in 
the child's condition, and are regarded as passing dis- 
turbances without much importance. When, however, 
they are entirely neglected, and excess of the food con- 
tinued, or even increased, due to wrong interpretation of 
symptoms, then more serious symptoms develop, and the 
condition reaches a stage where spontaneous cure rarely 
occurs. 

Vomiting becomes habitual, occurring from a few 
minutes to half an hour after nursing. It is accom- 
panied by visible discomfort and straining on the part of 



NUTRITIONAL DISTURBANCES. 79 

the infant. The vomitus consists of curdled milk, mucus, 
and gastric juice. Between vomiting there is often pain- 
ful belching. Stomach shows distention, and empties 
itself only after three to four hours. Free hydrochloric 
acid is almost or entirely absent,, the acid products of fer- 
mentation being present. The micro-organisms are in- 
creased in number and variety, due to stagnation and ab- 
sence of antiseptic free hydrochloric acid. 

Initial diarrhea is sometimes followed by temporary 
constipation, diarrhea setting in again. The evacuation 
is painful, and, with much gurgling and discharge of 
gases, fluid masses are squirted from the anus. The 
stools are watery, with white and dark green fragments, 
and of disagreeable, sour, pungent odor. The irritating 
feces often causes eczema and intertrigo in the ano- 
genital region. 

Abdomen is distended, tense, and often there is visible 
peristalsis. Intestinal colic causes restlessness and cry- 
ing ; the infant's face gives expression to its pain, and, as 
the fermentation increases, its agony is increased, due 
to intestinal paresis. 

The infant becomes restless; its sleep is much dis- 
turbed, and even during sleep its features give evidence 
of its distress. 

The weight early becomes stationary, and in severer 
cases associated with dyspepsia loss of weight becomes 
marked. 

Complications. Dyspepsia. Accompanied by the 
milder evidence of intestinal irritation, evidenced by in- 
creased peristalsis, with its resultant colic, more or less 
numerous bowel movements of eight or ten or even more 
daily, sour and irritating, greenish-yellow in color, and 



80 



INFANT FEEDING. 



containing numerous curds and much mucus. The but- 
tocks soon become reddened and intertrigo results. 

Intoxication, while rare in the breast-fed infant, may 
result when the dyspepsia is neglected. The baby be- 
comes drowsy and stuporous, paying little attention to 
its surroundings, and not infrequently develops a severe 
anorexia, all associated with more profound intestinal 
symptoms. 

In dyspepsia the intestinal findings dominate the pic- 
ture, while in intoxication they share their prominence 
with the added nervous symptoms. 

Pyelitis is not an infrequent complication in neglected 
dyspepsia and intoxication, and while it undoubtedly is 
frequently due to an ascending infection, it may re- 
sult from extension through the blood stream or the 
lymphatics. 

Eczema not infrequently results from overfeeding in 
the breast-fed infant, and is usually seen in the fat type 
of infant who is otherwise healthy. 

Pylorospasm, gastric dilatation are not uncommon in 
the neglected cases. 

Acidosis may develop in the extreme cases, associated 
with great loss of weight, but this is rare. 

Diagnosis. In the presence of symptoms suggestive 
of overfeeding, positive diagnosis is made by determin- 
ing exactly the amount of milk taken by the infant, and 
comparing this amount with what an infant of the same 
weight and of the same age should get. The method of 
this determination has been described in detail under the 
treatment of underfeeding. 

If, however, the food is found to be quantitatively cor- 
rect, occasionally information of value may be obtained 
by examining the quality of the milk chemically, espe- 



NUTRITIONAL DISTURBANCES. 81 

daily as to its fat content. The specimen for examina- 
tion should be taken under precautions pointed out under 
Examination of Human Milk. By making proper etio- 
logical diagnosis, valuable indications for rational treat- 
ment are obtained. 

If a careful search is made for the etiological factors 
dn the common illnesses of infants, which are so fre- 
quently charged to overfeeding, one will be surprised to 
find that the error lies in the diagnosis, and that in most 
cases the condition is not due to overfeeding. This leads 
us to warn against the only too frequent habit of wean- 
ing infants without a careful study of the exact cause 
of the infant's trouble. 

Treatment. Prophylaxis of this disturbance is of 
importance, and consists of giving the nursing mother 
proper instructions as to the nursing, especially as to its 
frequency, and seeing to it that the rules for nursing, as 
laid down elsewhere, are observed by the nursing mother 
In wet-nursing, more caution is necessary, especially in 
those wet-nurses who have an abundance of milk, which 
is frequently the case in a wet-nurse whose own child is 
much older than the infant to be nursed. 

A very important point to impress both on the mother 
and also on the wet-nurse is the fact that crying of the 
infant is not always due to hunger, and that offering the 
breast should not be used as a means for quieting the 
child. 

"When the initial or mild symptoms only are present, 
then correction of the nursing habits is usually sufficient, 
the infant improving without any special treatment. 

When the error lies in too frequent nursings, it is best 
and often completely relieved by lengthening the feed- 
ing intervals to three or, even better, four hours. 

G 



82 INFANT FEEDING. 

It is of equal importance that the infant should not be 
left too long at the breast. The best average nursing time 
being about fifteen minutes, with twenty minutes as the 
maximum. However, when the flow of milk is very free, 
it may be necessary to reduce the nursing period to even 
three to five minutes, it being a fact that most infants 
take about 75 per cent, of their entire meals in the first 
five minutes at the breast. It is always well at the begin- 
ning of such an experiment to weigh the baby after a 
two, three, five, ten, and twenty minutes period to ascer- 
tain the exact amount which the baby obtains from the 
particular breast which it is nursing, so that conclusions 
may be drawn definitely as to the time it is to be left on 
each breast. 

If placing the infant at the breast for short periods 
with long intervals does not give results, it is advisable 
to express the milk, and feed in small quantities from the 
bottle. And if another baby be at hand, it may be placed 
upon the breast to keep up the supply. Or when a wet- 
nurse is available for temporary use, the babies may be 
exchanged. 

Weaning should under all circumstances be considered 
only as the last resort, after all other methods of adapt- 
ing the infant to the breast have failed. 

An excessive amount of fat in the milk is more often 
due to an excessive intake of food in general on the 
mother's part than an excess in any one element, and can 
be diminished best by cutting down the food as a whole, 
lessening the amount of all food. 

When the condition has progressed farther, and the 
symptoms have become more serious, then it is necessary 
to treat the infant also. The treatment consists in empty- 
ing the stomach and the bowels of the overload of fer- 



NUTRITIONAL DISTURBANCES. 83 

meriting food, and of rest for the digestive apparatus, 
both these objects being achieved by giving a bland diet, 
consisting of boiled water or weak tea sweetened with 
saccharin, for twelve hours, the digestive tract getting rid 
of its contents spontaneously. 

If the symptoms improve upon this treatment, the 
nursing should be gradually resumed by giving two 
breast feedings in the twenty-four hours following the 
period of starvation, substituting for the other nursings 
bland liquids, and increasing cautiously the number of 
nursings. 

If on withholding the food, vomiting does not cease, 
then it is necessary to wash out the stomach. 

Irrigation of the bowel is often necessary, and aids in 
removal of fermenting intestinal contents, and allows 
also the gases to pass, thus relieving the distention and 
colic. Only when change of diet and irrigation are not 
sufficient, then the use of purgatives is advisable, castor 
oil being just as efficient and less harmful than the fre- 
quently preferred calomel. 

Colic usually disappears on correction of the diet, and 
after the intestinal tract has been cleansed of its irritating 
contents, and of gas. Massage to the abdomen will aid 
the passage of gases which cause distention, when the 
bowels tend to become paretic. In severe pain, warm 
applications to the abdomen give relief. If these meas- 
ures fail to bring relief, and the pain is such that the in- 
fant is deprived of sleep, a mild sedative in small doses 
may be given. 

Feeding of powdered casein in amounts varying from 
6 to 8 Gm., dissolved in 30 to 60 mils of water, two or 



84 



INFANT FEEDING. 



three times daily will relieve colic in many infants, in 
all probability due to lessening of intestinal peristalsis. 

There is a class of infants who, although they are gain- 
ing progressively in weight, cry a great deal, expel a 
great deal of gas, and perhaps have a green stool now and 
then. It is almost criminal to take such infants off the 
breast, although the temptation to do so is very great, 
because of the worry they cause the mother, and conse- 
quent harassing of the physician. Such an infant will 
frequently cry for six, eight, ten, or twelve hours out of 
the twenty-four, and still make a good gain in weight 
each week, in which case it is very probable that the 
infant is being overfed, and the food supply should be 
reduced. The mother's diet and general habits should 
receive attention. 



3. Congenital Debility, with Resulting Impair- 
ment of Vital Functions. 

Etiology. Premature birth is the most important 
condition causing debility associated with deficient func- 
tionating power of the digestive organs. Method of 
feeding premature infants will be detailed later in a 
special chapter. 

Hereditary weakness of the offspring caused by dis- 
ease in the parents is frequently the cause of deficient 
morphological and functional development of the diges- 
tive organs, and thus it is often the underlying cause of 
nutritional disturbances, which are more commonly 
chronic in character. Tuberculosis, syphilis, and alco- 
holism in parents stand at the head of the conditions 
causing hereditary weakness, even when the offspring 
does not inherit the disease itself. 



NUTRITIONAL DISTURBANCES. 85 

Malformations of the digestive tract (cleft palate, 
sublingual tumors, pyloric stenosis, atresias of the intes- 
tinal tract, Hirschprung's disease, etc.) from any cause 
compromise^ its functional capacity usually, but in most 
cases they cause serious conditions necessitating surgical 
interventions, and only rarely do they produce simple 
nutritional disturbances amenable to dietetic means, and 
therefore they belong to the domain of surgery. 

Symptoms. As may be expected, symptoms of these 
so diverse conditions vary. Hereditary weakness may 
often be suspected when symptoms of nutritional dis- 
turbances develop even when the infant is given the best 
care possible, and the milk is quantitatively and quali- 
tatively correct. Symptoms of underfeeding or of over- 
feeding, as described previously, may be present, de- 
pending upon the etiological factor. 

Diagnosis. Careful examination for malformations, 
and thorough family history, in cases of suspected 
hereditary weakness are of chief importance in making 
the etiological diagnosis. 

Treatment is usually determined by the pathology, 
and by the nature of the particular nutritional disturb- 
ance which developed. 

4. Intercurrent Parenteral and Enteral Infections. 

Etiology. Diseases both in the mother and in the 
infant are to be considered in etiology of this condition. 
In the mother the most important are the general infec- 
tious diseases, e.g., puerperal fever and sepsis, typhoid, 
pneumonia, etc., and local infections of the breast, and 
also of the upper respiratory passages. In the infant 
there are parenteral infections, that is, infections outside 
the digestive tract, e.g., pharyngitis, tonsillitis, pneu- 



86 INFANT FEEDING. 

monia, pyelitis, bronchitis, and enteral infections, or in- 
fections of the intestinal tract, which will be discussed 
under a special heading. 

Symptoms. In the conditions dependent on the 
mother's health the symptoms will vary first with the 
quality and quantity of her milk supply, which will have 
an effect on the child's general nutrition, and, secondly, 
may result in direct parenteral or enteral infections of 
the infant. 

In those dependent on infections of the infant itself we 
invariably find evidences of nutritional disturbances, 
whether the infection be local, systemic, or confined to 
the intestinal tract. The clinical picture varies directly 
with the degree of disturbance of the metabolic function. 
While, as a rule, the enteral infections are more com- 
monly associated with grave disturbances of the infant's 
nutrition, it is not uncommon to find the infant severely 
affected in its ability to mfeet its nutritional needs by 
the parenteral infections. While any one of the above 
enumerated etiological factors may give rise to a marked 
clinical picture, it is to be remembered that this class of 
disturbances in the breast-fed infants are of minor im- 
portance as compared with those of the artificially fed 
(see Nutritional Disturbances in Artificially Fed In- 
fants). 

Diagnosis. The diagnosis of the primary seat of in- 
fection in the infant is of considerable importance in de- 
ciding the method of treatment. 

Treatment. Parenteral infections rarely call for re- 
straint in administration of food because of the asso- 
ciated anorexia, and the infant should be nursed (if pos- 
sible without danger to the mother) directly at her 
breast, 



NUTRITIONAL DISTURBANCES. 87 

In the case of enteral infections it may be necessary to 
withdraw the maternal milk and replace it by a short 
period of starvation, to be followed by small quantities of 
breast milk, either taken directly from the breast during 
short nursings, or it may be best to feed small quantities 
of expressed milk to the infant at regular intervals. 

Not infrequently it becomes necessary to feed these 
infants by catheter in order to sustain them. And this 
method of introducing their food should be begun suffi- 
ciently early to avoid a catastrophe. 

Under no circumstances should they be placed upon 
food other than the mother's milk when her state of 
health and the quality of her milk permit. 

Inert fluids, such as water, weak tea, broths made from 
young meats and young fowls, and cereal decoctions 
should be given between feedings to insure a sufficient 
intake of water. A careful record should be kept of the 
twenty-four-hour quantity of all fluids administered, in 
order to insure the child a sufficient water and food ad- 
ministration. 

For conditions in the mother which would justify 
weaning, see chapter on Weaning and Contraindications 
to Nursing. 

5. Idiosyncrasy Towards Mother's Milk. 

Etiology. This condition is very rare, although it 
may not be denied that it exists. The etiology and patho- 
genesis are as yet little understood. 

Diagnosis. The diagnosis of this disturbance should 
be made by exclusion of all other causes that may give 
rise to a similar symptom-complex. It may be confirmed 
by the change of the milk either by substituting a wet- 



88 INFANT FEEDING. 

nurse or cow's milk for maternal nursing, whereupon the 
symptoms improve. 

Treatment. The treatment depends upon the par- 
ticular symptom-complex which develops. Change of 
milk is imperative in cases in which idiosyncrasy is 
clearly established. The mother's milk should not be al- 
lowed to dry up during the period of experimentation, 
because of the possibility of an error in diagnosis. 



CHAPTER VII. 

METHODS OF FEEDING PREMATURE 
INFANTS. 

1. Infants Nursing at the Breast. 

In most cases we do not feed the more developed pre- 
matura infant on the first day. It may be wise, however, 
to place the infant on the breast two or three times dur- 
ing the last half of the first day, after the circulatory and 
respiratory functions are well established, so that the in- 
fant may become accustomed to nursing. We are now 
confronted with two important factors, first, the ability 
of the infant to nurse the breast; and secondly, sufficient 
and proper development of the nipples to allow of the 
infant's properly grasping the same. If the infant is 
sufficiently developed to take hold of a well-formed 
nipple, it should be placed at the mother's breast regularly 
at three-hour intervals on the second day, for two- or 
three- minute periods, even though there is little hope 
of the breasts secreting at this time. By this means the 
infant is trained to expect its food at regular periods, 
and at the same time the maternal breast is stimulated. 
When a wet-nurse can be supplied in the home who has 
her own infant with her, the latter can be used to stimu- 
late the breasts of the mother, and the new infant can 
have one of the wet-nurse's breasts set aside for its use. 
Where the infant is very weak, the breast set aside for it 
can be made to secrete more freely by simultaneously 
placing the wet-nurse's baby on the opposite breast dur- 
ing the period of nursing. 

(89) 



90 INFANT FEEDING. 

We have found this to be a very valuable expedient. 
However, with this latter method of procedure the quan- 
tity taken by the premature infant must be accurately 
measured to prevent overfeeding by weighing the in- 
fant before and after the nursing period. Nursing di- 
rectly from the breast has the added advantage of de- 
veloping the baby's sucking muscles, preventing con- 
tamination of the milk, and stimulating the breasts by 
the natural method. It should, however, be remembered 
that a weak infant may nurse the maternal breast for a 
considerable time, and yet the amount of food taken may 
be insufficient. This is especially true of that class of in- 
fants who are inclined to go to sleep at the breasts. Here, 
again, weighing is of the utmost importance. When the 
infant is too weak to nurse sufficiently to satisfy its 
needs, as ascertained by weighing, the nursing should be 
followed by substitute feeding with expressed milk, either 
by the bottle or one of the other methods to be described. 
These rules do not apply for the first and second day, 
when only rarely more than four or five meals should be 
given. In very weak infants, and those subject to re- 
gurgitation after taking small quantities of milk, it may 
be necessary to feed more frequently in periods varying 
from two to two and a-half hours, as may be indicated 
by the quantity retained, or better results may be obtained 
by catheter feeding (to be described later) with four- 
hour intervals. 

2. Infants Too Weak to Nurse the Breasts. 

In this class of infants, wherever possible, they should 
be fed without being removed from their bed or the in- 
cubator, if usedj so as to avoid all careless exposure of 



FEEDING PREMATURE INFANTS. 91 

the infant. The cause of inability to nurse may be due 
to several factors: (1) Infants unable to swallow; this 
is usually because of improper development of the center 
in the medulla, or lack of co-ordination on the part of 
the pharyngeal muscles and tongue. This is usually made 
evident by the milk flowing from the dependent part of 
the mouth. In such cases it is generally necessary to re- 
sort to catheter feeding. (2) Those too weak to nurse, 
and who may appear to be almost dead ; in this class there 
is great danger in handling the infant, and it is best fed 
in the bed. (3) Those who will not suck. (4) Those 
vomiting after every feeding. (5) Those becoming 
cyanotic after feeding. In the latter cases it may even be 
necessary to resort to such methods as gentle friction, 
artificial respiration, best performed by gently compress- 
ing the thorax, warm baths, oxygen, etc. 

Methods. One of the following methods can be se- 
lected for feeding these infants : 

1. The nasal spoon, which can be used either by pour- 
ing the milk slowly into the nose or into the mouth. The 
latter is to be preferred, because of the dangers due to 
decomposition of the milk in the nose and naso-pharynx, 
with secondary development of rhinitis and pharyngitis. 

2. A medicine dropper for mouth feeding. This is 
possibly one of the best methods for feeding this class 
of infants, as it is simple of application, and a small 
dropper is easily obtainable. As in all other methods, the 
food should be administered very slowly. 

3. Nursing From a Bottle. For this purpose the small 
nipples commonly sold on doll nursing-bottles are of the 
proper size, and can usually be obtained of proper quality. 
We have not infrequently perforated the rubber end of 
a medicine dropper and used it for this purpose. The 



92 



INFANT FEEDING. 



bottle to be used can either be an ordinary 1-ounce or 2- 
ounce medicine bottle, or, better, the special bottle which 
was designed by the author for this purpose. This bottle 



— 10 



Fig. 5. — Breck feeder for premature infants. 



holds 2 ounces of milk, is graduated in cubic centimeters, 
has a ground glass neck which coapts perfectly with the 
bulb on the special breast-pump, and which after being 
filled is corked with a ground glass stopper, and wdiich 
has the added advantage in that the milk is in no way 
handled after it leaves the breast. 



FEEDING PREMATURE INFANTS. 93 

4. The Breck Feeder. This has the added advantage 
that the milk can be passed into the pharynx without 
effort on the part of the child when it is too weak to 
nurse. This has the one disadvantage of too rapid feed- 
ing if not properly controlled. 

5. A rather slow but satisfactory method of feeding 
the infants is by expressing the milk directly from the 
nipple into the infant's month during the feeding period. 

6. Catheter Feeding by Mouth (gavage). For this 
purpose a small funnel is attached either directly or by 
means of a short piece of rubber tubing with a glass 
connection to rubber catheter. A Nelaton catheter is 
used (best a No. 14 French), about 25 to 40 cm. long 
(10 to 16 inches), marked in centimeters or inches, so 
that at all times its position can be estimated. The in- 
fant should be fed in the incubator, its crib, or on the 
dressing table. Its head should be slightly lower than 
the body. The passage of the catheter is usually effected 
without difficulty by grasping it as one would a pen, and 
passing it in the midline to the pharynx, gradually push- 
ing it into the esophagus. This is usually accomplished 
without difficulty, because of the poorly developed 
pharyngeal reflexes, and rarely results in retching or 
vomiting. In infants who retch during the passage of 
the catheter, vomiting may be expected because of the 
fact that these latter infants not infrequently belong to 
the spasmophilic group. The danger of passing the 
catheter into the larynx is minimal. It is rarely necessary 
to pass the catheter more than 10 centimeters (4 inches) 
beyond the infant's lips, and we have found it equally as 
practical to limit the passage of the catheter to 7.5 centi- 
meters (3 inches). In most instances this does not reach 
the stomach, but has the added advantage of preventing 



94 



INFANT FEEDING. 



trauma to the cardiac end of the stomach and the gas- 
tric mucosa. When a graduated catheter is not at hand, 
it may be marked at 10 centimeters with indelible ink, 
and this used as the maximum point for passage. A 




Fig. 6. — Apparatus for gavage and lavage. (Glass taken 
from Breck feeder.) When using for small infants the 
catheter should be attached directly to the funnel without 
the intervening rubber tube. 

fairly safe maximum for the passage of the catheter can 
be ascertained by measuring the distance from the glab- 
ella to the epigastrium in the individual infant. The de- 
sired quantity of milk is allowed to flow into the stom- 



FEEDING PREMATURE INFANTS. 



95 



ach, slowly, by raising the funnel only very slightly above 
the level of the body. After feeding, the catheter is 
firmly compressed to avoid all leakage into the pharynx, 
and the catheter then removed, but not too rapidly. The 




Fig. 7. — Introduction of catheter for gavage. 



milk to be fed should be measured in a graduated glass, 
and the latter kept close at hand in order that the amount 
given can at all times be estimated. 

A complete record of every feeding, both as to the 
time and the amount, should be kept. This is especially 
important in institutions where the nurses have a number 
of infants to observe, and is greatly facilitated by a time- 



96 INFANT FEEDING. 

clock registering the day, hour, and minute of each feed- 
ing. The nurse records the quantity of milk taken, which 
in breast-fed infants is obtained by weighing the infant 
both before and after feeding on an accurate scale, or in 
infants too weak to nurse by measuring the quantity in 
a graduated glass before feeding. 

3. Proper Time for Beginning Regular Feeding. 

Due to the tendency toward the rapid development of 
acute inanition in this class of infants, the greatest dan- 
ger is that of too long delay in establishing regular feed- 
ing. Therefore it is often impossible to wait for the 
mother's milk t6 appear. We believe that it is, however, 
unwise in most instances to attempt to feed with milk 
during the first twelve to twenty-four hours, rather pre- 
ferring to allow the circulatory and respiratory organs 
opportunity for proper accommodation to their new en- 
vironment. During this time the loss of body fluids 
through evaporation from the skin and respiratory tract 
due to the warmth of the incubator, and the excretions 
through the kidneys and bowels, should be recompensed 
by the regular administration of water or some other 
inert fluid. 

We have endeavored to administer about one-sixth of 
the body weight of water (inclusive of that contained in 
the milk if given) in twenty-four hours. 

In smaller infants the first milk is given diluted one 
to four times during the first four days. After the first 
twenty-four hours water can be administered partly with 
the food, and otherwise between feedings. If for any 
reason the water is not well retained when given by 
mouth, it can, at least in part, be administered by rectum. 



FEEDING PREMATURE INFANTS. 97 

Example: An infant weighing about 1200 grams should 
receive 200 mils of water; should this infant receive 50 
mils of milk, this can be diluted with 50 mils or more of 
water or sugar solution, and the remaining 100 mils ad- 
ministered between feedings. If a stimulant is indicated, 
a few drops of brandy (6 to 15 in twenty-four hours) 
may be added to the water or sugar solution during the 
first twenty-four hours. Half strength of Ringer's solu- 
tion prepared as follows can be used to good advantage 
for rectal administration: 

NaCl 7.5 Gm. 

KC1 0.1 " 

CaCl 0.2 " 

Water 1000.0 mils. 

We have made it a rule never to start milk feeding 
until after the first bowel movement. Not infrequently 
the removal of meconium may be accomplished by the 
administration of a small quantity of physiological salt 
solution through a catheter passed one or two inches 
into the rectum. This is done to remove the meconium 
before infection of the intestinal tract through the 
administration of food. Occasionally it is necessary 
to administer 5 drops of castor oil to obtain slight 
purgation. 

4. Feeding From the Second to the Tenth Day. 

It must be remembered that the general rules as ap- 
plied to the feeding of premature infants do not hold 
for the first ten days of life. The early feedings must 
necessarily be small, and the increases gradual. Two 
grave dangers present themselves during the first period 
of the infant's existence: (1) overfeeding and (2) star- 



98 INFANT FEEDING. 

vation, the latter usually resulting from an inability to 
supply sufficient quantity of human milk, following an 
attempt to await the natural secretion of the mother's 
breast. Overfeeding results either in vomiting or, more 
seriously, in stomach distention, which leads to asphyxia 
and cyanosis. Underfeeding in these weak infants soon 
leads to inanition. From the second day these infants 
should be fed regularly day and night, every two or, 
better, three hours, depending upon the infant's condition 
and the method of food administration. Not infre- 
quently where the quantities taken are very small, ten to 
twelve feedings are required in twenty-four hours. It 
may even be necessary in very weak infants to feed 
minimal quantities every hour. The question of the 
number of feedings will be discussed in detail later. 

It is practically impossible to formulate definite rules 
for feeding premature infants during the first ten days, 
because of their great variation in weight and develop- 
ment. Therefore it becomes necessary to feed each in- 
fant individually. 

During the first days it is often difficult in infants 
weighing 1000 to 1200 grams or less to feed more than 
20 to 50 mils of milk per day, and it may be necessary to 
limit the food to this quantity during the first ten days. 
It is our rule to start feedings in this class of cases with 
a maximum of 4 mils per feeding, not infrequently using 
one-fourth or one-half human milk at the start, and the 
balance water. ' 

The feedings should be increased by 1 mil at a time, 
and with the first evidence of regurgitation the quantity 
should remain stationary, Even in favorable cases dur- 
ing this time 30 to 50 calories per kilogram is likely to 
be the maximum that can be fed with impunity. 



FEEDING PREMATURE INFANTS. 99 

The small feedings which can be assimilated, and the 
low energy quotient during the first two or three weeks, 
must be considered physiological, and as we rarely see 
an increase in weight with feedings of less than 90 cal- 
ories per kilogram, we are confronted by a rapid loss in 
body weight during the first days of life. In favorable 
cases this is usually followed by a stationary weight, or 
moderate fluctuations after the first four to seven days. 
Occasionally an infant is seen in whom there is sufficient 
water retention to avoid most of the initial loss in weight. 
One should, therefore, remember that even with fre- 
quent feedings with human milk, either at the breast, by 
hand, or gavage, it is rarely possible to feed more than 
the minimum requirements without causing vomiting. 

5. Feeding After the First Ten Days. 

There has been considerable discussion as to the food 
requirements of premature and underweight infants 
during the past few years. Budin gives us the rule that 
premature infants of less than 2500 grams after their 
tenth day require one-fifth of their body weight (200 
Gm. per kilogram of body weight), or 140 calories, while 
the full-term infant of normal development requires one- 
seventh of its body weight (140 Gm. per kilogram body 
weight), or 100 calories per day. On the other hand, 
Birk believes that the more fully developed premature 
infant, and those nearing the normal, will thrive on one- 
sixth to one-seventh of their body weight. 

Our opinion, based on a series of experiments made 
on a number of premature infants, is that they require 
higher food values, or at least the maximum required by 
normal infants, for the following reasons: (1) the 



100 INFANT FEEDING. 

greater body surface as compared with the body weight ; 
(2) in the normal infant the requirements decrease with 
the age, and therefore in the premature the quantity re- 
quired varies inversely with the fetal age after the first 
weeks of life; (3) the need for body development is 
relatively greater in the premature than in the full-term 
infant; (4) a kilogram of body weight in the fat-poor 
premature infant cannot be taken as parallel in feeding 
to the well developed full-term infant, with its prepon- 
derance of fatty tissue. This latter point must also be 
considered in the feeding of the marasmic infant, to 
obtain a proper gain in weight as compared with the 
lower requirements in the fat, full-term infant. 

6. Number of Feedings Daily. 

Our own experience has led us to adopt a conservative 
position in that we have grouped the infants nursed at 
the breast or fed from the bottle or by feeders into two 
general classes: (1) those weighing under 1500 Gm., 
and (2) those above this figure, based on the tendency 
of the smaller infants to become exhausted when the 
feedings are long continued. The former are fed at 2- 
hour intervals during the day, and 3-hour intervals at 
night, as follows: 6 a.m., 8 a.m., 10 a.m., 12 m., 2 p.m., 
4 p.m., 6 p.m., 9 p.m., 12 p.m., and 3 a.m. — 10 feedings 
during the twenty-four hours. The larger infants are 
fed on a 3-hour basis, 8 feedings being given during the 
twenty-four hours. These figures should in no way be 
construed as arbitrary. All feedings are more or less 
dependent upon the general development of the infant in 
relation to its digestion and metabolism, its retention, 
and upon the larger quantities of food necessarily given 
to meet its nutritional requirements, and a careful atten- 



FEEDING PREMATURE INFANTS. 101 

tion to gastric distention, regurgitation, asphyxia, cya- 
nosis, and other respiratory complications. 

It has been our personal experience to meet with con- 
siderable difficulty in attempting to meet the large food 
requirements in smaller infants without resorting to 
catheter feeding. In these we have adopted the longer 
interval between feedings, of four hours with six feed- 
ings in twenty-four hours, the individual meal in catheter 
feeding being greater in quantity. Notwithstanding the 
fact that catheter feeding offers little difficulty and few 
dangers in experienced hands, this may not be true with 
those not skilled in its use. A considerable number of 
our cases have, however, thrived satisfactorily on quan- 
tities of milk less than one-fifth of their body weight per 
day, and one should always remember that it is a safe 
axiom not to force the feeding in these cases as long as 
their general development is progressing satisfactorily 
and their weight curve is good. 

7. The Amount of each Feeding. 

The statistics as to the stomach capacity for food in 
premature infants indicate that this varies within con- 
siderable limits, even in infants of the same fetal age, as 
does also their ability to digest and assimilate food. 
The weight and length, naturally excluding congenital 
diseases and deformities, will be far more dependable as 
a guide to stomach capacity than the fetal age. As no 
definite rules can be established governing the amounts 
of individual feedings, we begin with what could be 
considered minimum quantities and gradually increase 
the amount of feedings as the infant develops an ability 
to digest it. It is our rule, as previously stated, during 
the first few days to feed small total quantities varying 



102 INFANT FEEDING. 

from 20 to 50 mils of milk per day, dividing these totals 
by the number of feedings to be administered (eight to 
ten), thereby feeding from 2 to 6 mils of milk per feed- 
ing. The feedings can then be increased by 1 or more 
mils at a time, and in the absence of vomiting the in- 
dividual feedings can be increased more or less rapidly 
until the weight loss ceases or an increase in weight oc- 
curs. Even in favorable cases, weighing over 1500 Gm., 
45 to 75 mils per kilogram weight (30 to 50 calories per 
kilogram) is likely to be the maximum that can be fed 
with impunity or safety during the first ten days. 

8. Daily Gains. 

These are not necessarily in proportion to the changing 
quantity of milk administered, as many factors, such as 
condition of the bowels, quantity of the urine passed, 
temperature of the infant's surroundings, will neces- 
sarily influence the weight. This is more especially 
noticeable in observations continued during a short period 
of time. An average greater daily gain than 20 Gm. 
is unusual when the infant's food is limited to one-fifth 
of its body weight. An average of from 10 to 20 Gm. 
daily can in most cases be considered satisfactory. 

9. Artificial Feeding. 

There can be no comparison between the results to be 
expected in feeding premature infants on human milk, 
and those to be obtained with artificial food. With 
human milk taken from a well regulated department for 
wet-nurses the milk can be obtained fresh, practically 
sterile; it is more digestible; its constituents are of the 
quality and in the proportions required for the growth 
and development of the human body; and it is live, and 



FEEDING PREMATURE INFANTS. 103 

contains many of the immunity-conferring properties, as 
evidenced by the resistance of a breast-fed infant to in- 
fections and contagious diseases. Most of these proper- 
ties and advantages are lacking in the dead foods used 
in artificial feeding. Therefore, if it becomes necessary 
to resort to artificial feeding, the selection of the food, 
its preparation, and its adaptation to the infant must all 
be given the most painstaking consideration. Many 
varieties of artificial diet have been suggested by various 
authors, such as simple milk dilutions, cream and top- 
milk mixtures, skim and buttermilk mixtures, malt soup 
preparations, condensed and evaporated milk, etc. The 
results with the various diets are to a great degree de- 
pendent upon the physician's intimate understanding of 
and directions for the use of the individual food. 

Quantity of Food. It must be remembered that the 
figures quoted for feeding on breast milk are the maxi- 
mum that can be assimilated, and in most instances these 
amounts more than fulfil the immediate needs of the 
infant's existence, and can be considered (and in most 
instances would be) excessive quantities for artificial 
feeding in the first few weeks of life, because of the 
greater difficulty in the digestion of cow's milk. One 
hundred calories per kilogram is the maximum quantity 
that can be digested by most premature infants, and in 
many instances one must be satisfied with a sustaining 
diet bordering on 70 to 80 calories, and they must at all 
times be closely watched for evidence of overfeeding, as 
it is dangerous to exceed the actual food requirements, 
and the first evidence of digestive disturbances or of in- 
tercurrent infections should lead to the feeding of human 
milk. During the first days the same rules for minimal 
feedings must be observed as in feeding with breast milk. 



104 INFANT FEEDING. 

Quality of Food. Opinions vary greatly as to the 
best food for an artificial diet. Ordinary milk, water 
and sugar mixtures are rarely well taken. Pfaundler sug- 
gests rich fat and low protein milk mixtures ; but in this 
feeding we have seen fat diarrhea resulting. Budin ob- 
tained the best results with peptonized boiled milk, using 
fresh pancreatic extracts for this purpose. Finkelstein, 
Oberwarth, Birk, Neumann, Von Reuss have obtained 
their best results through the use of boiled buttermilk 
mixtures, prepared according to the following formulae: 

Buttermilk 1000 

Flour 10 

Sugar 40 

The above being used for the first feedings. 

Buttermilk 1000 

Flour 15 

Sugar 60 

For later feedings. 

Dextrin-maltose compounds can be substituted for the 
cane-sugar if desirable. 

Chymogen or pegnin milk has given us most satis- 
factory results in the artificial feeding of the premature 
infants. This latter preparation is little more than 
a boiled milk in which the curds are precipitated in 
a fine, flocculent form, about the size of that of human 
milk, before it is fed to the infant. It is best diluted be- 
fore use. This preparation should be started with 1 part 
chymogen milk and 3 parts water, following the direc- 
tions for increases in quantity and quality as given for 
human milk. Because of the low carbohydrate content 
of such mixtures, 0.5 per cent, of lactose should be 
added after the first few days, and the amount gradually 
increased to 3 per cent. 



FEEDING PREMATURE INFANTS. 105 

When even only insufficient amounts of human milk 
can be obtained, artificial feeding should be used as a 
supplement and not as a substitute. 

10. Conclusions. 

1. The weight, temperature, stools, absence of ab- 
dominal distention, cyanosis and well-being of the infant 
should be the guide for increase in the infant's diet. 

2. The utmost care is necessary in increasing the diet 
of the infant during the first days of life. The gastro- 
intestinal tract offers the test evidence for increases. 
Vomiting and abdominal distention and associated cya- 
nosis are the prime indications for stationary or de- 
creased amounts of feeding. 

3. An initial weight loss during the first ten days must 
be considered physiological. 

4. These infants, therefore, should be fed small quan- 
tities, frequently repeated, every two to three hours dur- 
ing the day and night. 

5. On the first day human milk may be fed diluted 
with one or two parts of water and sugar, with a caloric 
value approximating 15 to 30 calories (20 to 40 mils, 
% to 1% ounce of human milk to the kilogram of body 
weight). 

6. From the second day on, in the absence of indiges- 
tion, the food may be increased by 10 calories daily per 
kilogram (15 mils daily per kilogram). In the presence 
of digestive disorders greater care is necessary to main- 
tain the metabolic equilibrium (120 mils, 4 ounces of 
milk to the kilogram of body weight). 

7. It is of the greatest importance to administer a 
sufficient supply of water to counterbalance the rapid 
evaporation due to artificially heated and dried air, and 



106 INFANT FEEDING. 

the excessive excreta, more especially during the first 
few days. About one-sixth of the body weight of water, 
inclusive of that contained in the milk, should be fed in 
twenty-four hours. 

8. It is to be remembered that a standstill in the weight- 
curve, and indigestion with bad bowel movements, fre- 
quently result when 140 calories per kilogram are 
exceeded. 

9. All intestinal disturbances in premature infants 
should be given the utmost consideration. 

10. The method of administration of food in each case 
varies with the vitality of the infant. 

11. In all cases of prematurity, syphilis should be 
thought of; and in cases in which there is the slightest 
suspicion, the infant must not be placed directly on the 
breast of a wet-nurse. 

1.2. Full description of a newly devised Electric- 
Heated Water-Jacketed Infant Bed, designed by the 
author, see Appendix, page 310. 






PART III. 
Artificial Feeding. 



CHAPTER I. 

RECENT PROGRESS IN ARTIFICIAL 
FEEDING. 

The presentation of the subject of artificial feeding 
without a review of the progress and evolution which 
our ideas on this subject have undergone during the past 
years might easily mislead the student to the belief that 
the last word in artificial feeding of infants has been 
said. The men who have given this subject the most con- 
sideration, we believe, would agree that much is to be 
hoped for in the future in artificial feeding. 

It is most difficult to present in a concise manner the 
best that we have learned in artificial feeding so that it 
may be practically applied, because of two very important 
factors which make for success: (1) a careful interpre- 
tation of the needs of the individual infant, and (2) ex- 
perience on the part of the feeder to meet those needs. 

It remained for the American school of pediatrics to 
do the pioneer work in placing artificial feeding on a 
scientific basis. 

Pepper and Meigs, of Philadelphia, gave us the first 
rational method in milk modification. They more espe- 
cially attempted to vary the percentages of casein in 
cow's milk, believing that the excessive quantity con- 
tained in cow's milk was in great part the cause of feed- 

(107) 



108 INFANT FEEDING. 

ing difficulties. This was accomplished by diluting the 
milk and adding milk-sugar and cream to make up the 
deficiency in energy value. 

Rotch, of Boston, made further advances in infant 
feeding in that he taught us that fat and sugar, as well 
as protein, were important factors in the disturbances of 
the artificially fed infants. His work on percentage feed- 
ing, whereby he increased or decreased the various con- 
stituents of human milk to meet definite clinical pictures, 
was probably the first epoch-making advance in infant 
feeding, and his system of feeding has since been known 
as "the percentage method" of infant feeding. 

The German school, of which Rubner and Heubner 
were the chief advocates, gave us the so-called "caloric 
method" of feeding, by which they sought to provide the 
number of heat units required by the infant, basing their 
estimations on the infant's weight. Of this method we 
will have occasion to speak later. It is sufficient to state 
that we do not now use this as a method of feeding, but 
find a check on the caloric contents of the food of in- 
estimable value in determining the value of our mixtures 
in avoiding over- and under- feeding. The German 
school have never attempted the refinements in the per- 
centage composition of their mixtures as advocated by 
the American school. 

More recently Czerny and Finkelstein have taught us 
the dangers of overfeeding with whole milk, and also its 
individual ingredients, fat, sugar, and salts, individually 
and in combination. Their studies have, on the whole, 
ignored the proteins, in all probability due to the fact 
that protein disturbances other than those seen in infants 
suffering from an idiosyncrasy to cow's milk are for the 
most part limited to infants fed on raw cow's milk, 



PROGRESS IN ARTIFICIAL FEEDING. 109 

while most of the Continental clinics have for several 
years fed boiled milk: Their studies and conclusions will 
be more fully discussed under the disturbances of arti- 
ficially fed infants. 

During the past few years there has been an increased 
tendency to boil cow's milk before feeding to the infants 
in American clinics, based on the desire to render the 
curd more fragile, and at the same time to destroy the 
pathogenic bacterial content of the milk. While this has 
many advantages, it must not be forgotten that it must 
necessarily cause changes, more especially in the fer- 
ments, vitamines, and salts, which are of vital importance 
to human economy. The ferments are believed to be im- 
portant to the infant, and this importance has been em- 
phasized especially since the introduction of pasteuriza- 
tion and boiling of milk, for the reason that a high degree 
of heat destroys them. Some of the ferments are normal 
constituents of milk, such as lipase, galactase, lacto- 
kinase, and diastase. The absence of ferments in the 
milk indicates that it has been heated. Hamburger's 
studies on the biologic differences in human and cow's 
milk are unquestionably of vast importance, and though 
there has been a tendency in recent years to neglect this 
factor in infant feeding, we believe that it will again 
receive more important recognition in the near future. 
The changes caused in milk by boiling make it necessary 
to administer fruit and. vegetable juices, non-dextrinized 
cereals, and other foods, such as codliver oil, to prevent 
the retarded development on the part of the infant. 



CHAPTER II. 
COW'S MILK. 

No method of artificial feeding can perfectly replace 
nursing or human milk feeding. This must be admitted, 
notwithstanding the many advances that have been made 
in infant feeding during recent years. 

The best substitute for nursing is feeding with prop- 
erly modified milk of other animals, and cow's milk, for 
practical reasons, was found to be the one best suited for 
this purpose. 

There are marked chemical, physical, and biologic dif- 
ferences between the human milk and cow's milk, which 
account for the superiority of human milk over the cow's 
milk in infant feeding. 

How Cow's Milk Differs from Maternal Milk. The 
differences between' these two milks summarized in a 
table which follows are greater than the table indicates. 
While cow's milk may be modified to approximate 
woman's milk in composition, it can never be just the 
same or just as good for infants. 

Cow's milk is more opaque than human milk, although 
the latter may contain a greater percentage of fat. This 
is due to the opacity of the calcium-casein, which is pres- 
ent in greater proportion in cow's milk. Cow's milk is 
faintly acid or amphoteric when freshly drawn, but ordi- 
narily is distinctly acid in reaction when consumed. 
Human milk is amphoteric or alkaline. 

There is three times as much protein in cow's milk as 

in human milk. The reason for this is obvious, when we 

recall that the ratio of the growth of the calf to that of 

the infant is about as 2: 1. Furthermore, the protein in 

(110) 



COW'S MILK. Ill 

cow's milk consists chiefly of casein (3.02 per cent.) and 
little lactalbumin (0.53 per cent.), while human milk con- 
tains 0.59 per cent, of casein and 1.23 per cent, lactal- 
bumin. The sugar in the two milks varies greatly in 
amount, but not in kind. Cow's milk contains almost 
four times the amount of inorganic salts compared to 
woman's milk. In cow's milk calcium and magnesium 
are in greater proportion, while in woman's milk potas- 
sium and sodium bases are in relatively greater amounts. 
These differences have an important bearing upon 
infant's metabolism. There is no great difference in the 
average amount of fat in the two milks; however, both 
in human milk and in cow's milk the fat is the most 
variable constituent. 

The curd from cow's milk is usually tougher and in 
larger masses than in human milk. There are also dif- 
ferences in antibodies, ferments, etc. 

Cow's Milk. Human Milk 

Amphoteric or acid Reaction Amphoteric or alk- 
aline 

1.029 to 1.034 Sp. gr 1.010 to 1.040 

3.5 per cent Proteins 1.5 to 2.0 per cent. 

3.02 per cent Caseinogen 0.5 to 0.75 per cent. 

0.53 per cent Lactalbumin 1.23 per cent. 

Clots in large lumpy 

curds Effect of rennin Clots in fine curds 

4.0 per cent .Fat 3.5 to 4.0 per cent. 

4.5 per cent Lactose 6.0 to 7.0 per cent. 

0.75 per cent Salts 0.2 per cent. 

13 to 14 per cent. . . .Total solids 12 to 13 per cent. 

86 to 87 per cent. . . . Water 86 to 88 per cent. 

Never sterile Bacterial contents ...Practically sterile 

Biedert, whose theory found many followers at one 
time, believed that casein of the cow's milk was the dis- 
turbing factor in artificial feeding. 



112 INFANT FEEDING. 

The large, tough curds forming from the casein of raw 
cow's milk differ considerably from the fine flocculent 
curds of the human milk casein. Steps have been taken 
to make the cow's milk curd resemble the human milk 
curd in its physical properties, such as boiling the milk, 
citration and addition of cereal waters, and it was found 
that this modification considerably improved the results 
of artificial feeding. 

The differences in the fat contents of the two milks 
have less frequently been drawn upon for explanation of 
frequent nutritional disturbances on artificial feeding, 
although it has positively been established that fat plays 
an important part in the nutritional disturbances of the 
artificially fed infant. The butter prepared from cow's 
milk contains 10 per cent, of volatile acids, while that 
prepared from the human milk only 1.5 per cent. And 
especially the irritant butyric acid glycerid, which is con- 
tained in 6 per cent, in butter prepared from cow's milk, 
is contained only in traces in human milk. The fat drops 
of cow's milk are also on the whole much larger than 
those of human milk, p 

Lactose is the principal sugar in both cow's and human 
milk, average human milk containing 6 to 7 per cent., 
and cow's milk 4 to 5 per cent. This increased sugar 
contents of the human milk, with its fermentation, ac- 
counts for the laxative effect of breast milk feeding when 
the milk is abundant. 

L. F. Meyer has experimentally shown that salts of the 
cow's milk, which vary both quantitatively and qualita- 
tively from those of human milk, have unfavorable in- 
fluence on children with nutritional disturbances. While 
we cannot from these experiments conclude that the same 
holds true for normal, healthy children, yet we have to 



COW'S MILK. 113 

admit that the salt contents of the two milks are of great 
importance in artificial feeding. 

Escherich and Hamburger were of the opinion that 
human milk contained ferments which favorably influ- 
enced the processes of metabolism. Salge found that 
tetanus and diphtheria antitoxins could be utilized by the 
infant only when fed in human milk, while when con- 
tained in the milk of other species they did not get into 
the body fluids of the infant. But whether these biologic 
differences are of great importance to the infant remains 
to be proven. 

Although it seems probable, yet it has not been demon- 
strated that cow's milk feeding taxes the digestive func- 
tions of the infant's organism more than human milk 
feeding. 

Of great importance is the bacterial contents of the 
milk, the human milk being either sterile or of low bac- 
terial contents, while cow's milk is never sterile, and not 
infrequently its bacterial contents is very high. Steril- 
ized, pasteurized, and certified milk were the practical re- 
sults of the efforts to obtain germ-free milk for infant 
feeding. 

The milk for infant feeding must come from healthy 
cows, must be obtained in clean manner into clean re- 
ceptacles, must be cooled very soon after milking in order 
to keep down the bacterial content, and kept cool after- 
wards. It must be delivered to the consumer as soon 
as possible in such a way as to prevent any contamina- 
tion, and must be handled in the home, cleanly, in sterile 
receptacles, and at all times be kept cool. 

The cow from which the milk is obtained must be 

entirely healthy, and be especially free from tuberculosis 

and glanders, tuberculin and mallein test being advisable 

s 



114 INFANT FEEDING. 

as a routine, besides general examination of the cow. 
The cows must be kept clean, in a clean stable, which 
is well ventilated and drained. No dust, manure, or fod- 
der, except that used for immediate feeding, should be 
kept in the stable. The cows should be kept clean, but 
even then they should be cleaned again immediately be- 
fore milking. 

The milking must be done in a clean way and milk 
kept clean afterwards, in order that the bacterial count 
may be as low as possible. Dry feeding of the cows is 
preferable, since on this feeding the feces is less liquid, 
and cows can be kept clean with less difficulty. The 
milkers should be free from any communicable disease, 
and be of clean habits. The udders of the cows and the 
hands of the milker should be scrubbed with warm 
water and soap immediately before milking, and anti- 
septic solution may be applied afterwards. Milking 
should be done into covered cans, and milk made to pass 
through a filter first. The cans should be always cleaned 
immediately after the milk is poured out, first with cold 
and then with hot water, and also rinsed out with hot 
water before milking. The first few ounces of milk 
should be discarded, since this milk contains large 
amounts of bacteria that are washed out from the ex- 
cretory ducts. 

Cooling the milk after it is obtained is a very impor- 
tant step in the production of clean milk. The milk hav- 
ing been obtained with the above-described precautions, 
with as few bacteria as possible, should be cooled at 
once in order to prevent growth and multiplication of 
the bacteria that have entered the milk in spite of all the 
precautions. This is accomplished by special cooling ap- 
paratuses, or simply by pouring the milk into sterilized 



COW'S MILK. 115 

bottles, closing with sterilized cap, and putting on ice. 
The milk in bottles should be kept iced until it reaches 
the consumer, which should not take longer than twenty- 
four hours. 

In the home precautions should be taken to prevent 
additional contamination, and to keep the milk iced to 
prevent further growth of bacteria, until everything 
necessary is ready for making the proper mixture for in- 
fant feeding. Many good milks are spoiled on the door- 
step of the home between the hour of delivery and plac- 
ing the milk in the ice-box. All the utensils and vessels 
used for preparing the mixture must be perfectly clean 
and sterilized by boiling. As soon as the mixture is made 
it should be put into the ice-box again and kept there, 
portions being taken during the day for individual feed- 
ings, and warmed separately just before feeding. 

Certified Milk. The term "certified milk" was coined 
by Dr. Henry L. Coit, of Newark, N. J., who in 1892, 
needing good milk for his own baby, formulated a plan 
for the production of clean, fresh, pure milk under the 
auspices of a medical milk commission. The term "cer- 
tified milk," then, is the milk of the highest quality, of 
uniform composition, obtained by cleanly methods from 
healthy cows, under the special supervision of a medical 
milk commission. 

The use of the term "certified milk" should be limited 
to milk produced in accordance with the requirements of 
the American Association of Medical Milk Commission- 
ers. The first requisite in the production of certified 
milk is to enlist the co-operation of a trustworthy dairy- 
man who is willing to enter into a contract with the 
medical milk commission. In accordance with the terms 
of this contract, the dairyman binds himself to comply 



116 INFANT FEEDING. 

with the specifications set forth, and in return his milk 
is certified. 

The dairies are subjected to periodic inspections, and 
the milk to frequent analyses. The cows producing cer- 
tified milk must be free from tuberculosis, as shown by 
the tuberculin test and physical examination by a quali- 
fied veterinarian, and from all other communicable dis- 
ease, and from all diseases and conditions whatsoever 
likely to deteriorate the milk. They must be housed in 
clean, properly ventilated stables of sanitary construc- 
tion, and must be kept clean and properly fed and cared 
for. All persons who come in contact with the milk must 
exercise scrupulous cleanliness, and must not harbor the 
germs of typhoid, tuberculosis, diphtheria, or other in- 
fections liable to be conveyed by the milk. Milk must be 
drawn under all precautions necessary to avoid contam- 
ination, and must be immediately cooled, placed in steril- 
ized bottles, and kept at a temperature not exceeding 50° 
F., until delivered to the consumer. Pure water, as de- 
termined by chemical and bacteriological examination, is 
to be provided for use throughout the dairy farm and the 
dairy. Certified milk should not contain more than 10,- 
000 bacteria per cubic centimeter, and should not be more 
than thirty-six hours old when delivered. 

Inspected Milk. This term should be limited to 
clean, fresh milk from healthy cows, as determined by 
the tuberculin test and physical examination by a quali- 
fied veterinarian. The cows are to be fed, watered, 
housed, and milked under good conditions, but not neces- 
sarily equal to those prescribed in the production of cer- 
tified milk. Scrupulous cleanliness must be exercised and 
particular care be taken that persons having communi- 
cable diseases do not come into contact with the milk. 



COW'S MILK. 117 

This milk must be delivered in sterilized containers, and 
kept at a temperature not exceeding 50° F. until it 
reaches the consumer. There should be not more than 
100,000 bacteria per cubic centimeter of inspected milk. 
This milk should be pasteurized. 

Market Milk. All milk that is not certified or in- 
spected in accordance with the above definitions, and all 
milk that is of unknown origin, is classed as "market 
milk/' and should be pasteurized. 

Frozen Milk. In our own experience we have found 
that many infants were made ill by feeding of raw frozen 
milk which has been rapidly thawed, and allowed to 
stand in a warm room, with resulting vomiting, and not 
infrequently diarrhea. These symptoms are obviated 
when the milk is boiled. Pennington and her collabora- 
tors found very definite changes in milk after freezing. 
They found that when the milk is held at a temperature 
of 0° C. there is proteolysis of the casein, which is pri- 
marily of bacterial origin, and proteolysis of the lactal- 
bumin, due primarily to the native enzymes of the milk.. 
The action of these two agents together is more rapid 
than that of either alone. The bacteria and enzymes may 
break down the true protein and carry the breaking dow T n 
through to peptones, even to amino-acids. There is a 
fermentation of lactose with the formation of lactic acid, 
which is largely, if not exclusively, due to bacterial 
action. The fat, so far as can be determined, is not 
affected except by the action of bacteria. 

Mixed Milk Versus Milk of One Cow. It is far bet- 
ter, other things being equal, to use the mixed milk of a 
herd in preparing a baby's food than the milk of one 
cow, because if the milk comes from one cow, and the 
cow is ill in any way, the baby is almost certain to be dis- 



118 INFANT FEEDING. 

turbed, whereas if one or two cows in a herd are ill, the 
milk from these cows will be so diluted that the baby will 
probably not notice it. On the other hand, it is, or should 
be, self-evident that the milk of a healthy cow properly 
fed and properly cared for, taken in the proper way, and 
kept under proper conditions, is better than the mixed 
milk of a herd which is improperly fed, and whose milk 
is not carefully obtained or carefully taken care of. 

Boiling, Sterilization, and Pasteurization. Before 
entering into a discussion of this subject, it is only fair 
to state that the general teaching in America of feeding 
with raw milk has led to the production of safe, clean 
certified milk in the large communities where so many 
fatalities were experienced through the feeding of un- 
clean milk. Any methods of handling milk which will in 
the least interfere with the proper production of clean 
milk, and lead to the feeling that unclean milk can be 
made safe for infant feeding by the application of heat or 
other methods, would be a backward step in infant feed- 
ing, and would necessarily cause dire results. While the 
European countries, like Germany and France, have ad- 
vocated feeding boiled milk for many years without fear 
of bad nutritional disturbances due to tlje changes in the 
milk, in America feeding with raw milk has until re- 
cently been favored. Increased experience with boiled 
milk, especially by those who have long used raw milk, 
leads to the growing conviction that boiled milk is more 
easily digested than raw milk by dyspeptic infants, and 
hence by the well infants. 

While we* do not believe that feeding with boiled milk 
should be advised as a general measure, when it is pos- 
sible to obtain a good certified milk, and when the latter 
is to be placed in the hands of mothers and nurses who 



COW'S MILK. 119 

can be depended upon to keep the milk clean and whole- 
some through proper icing and handling, we do believe 
that when these requirements cannot be met, that it is 
safer even in well babies to feed a thoroughly sterilized 
milk, and that this can be done without danger of de- 
velopment of scurvy and rickets, when these feedings are 
accompanied by the administration of fruit juices, vege- 
table soups, and purees and codliver oil. 

Brennemann suggests that we must answer the follow- 
ing questions before deciding as to whether we should 
feed raw, pasteurized, or boiled milk: 

(1) Does raw milk offer advantages over boiled 

milk? 

(2) Does boiled milk offer advantages over raw 

milk? 

(3) Does pasteurization solve the problem? 

(4) Does certified milk solve the problem? 

In answer to the first question we must decide whether 
the changes caused in milk by boiling, such as partial 
coagulation of lacto-albumin, caramelization of some of 
the milk-sugar, its action on casein, inhibiting coagula- 
tion with rennin, etc., lessen the nutritive value of cow's 
milk as an infant food. We believe that the sentiment of 
American, German, and French clinics, in which boiled 
milk has been used for a long period of time, is to the 
effect that the nutritive value of boiled milk, with its les- 
ser dangers, are on the whole in favor of boiled milk. 

Constipation has been suggested as an argument 
against boiling milk. We believe that constipation in the 
bottle-fed baby is one of the safest earmarks of the well- 
being of the infant, and that only that constipation which 
is due to excessive feeding of fat, and which will be 
described under Disturbed Metabolic Balance, is an ex- 



120 INFANT FEEDING. 

ception to this statement. While with raw milk digestive 
disturbances are frequently seen before sufficient milk is 
given to properly nourish the infant, this is far less com- 
mon with boiled milk; in fact, it has not infrequently 
been our experience that we have overfed with boiled 
milk, because the infant handles it with so much better 
advantage. In digestive disturbances, with loose stools, 
it is digested to much better advantage than raw milk, 
which frequently results in formation of hard casein 
curds as well as fat curds. The assertion that feeding 
with boiled milk results in anemia, underdevelopment and 
rickets, we believe, is not well founded, and these condi- 
tions, when present, are due to other causes. Scurvy de- 
veloping during the course of feeding with boiled milk 
has never been seen in our experience, except when some 
of the proprietary infant foods have been fed in con- 
junction with boiled milk. That under certain conditions 
scurvy should develop in presence of long-continued feed- 
ing with boiled milk alone, is not to be denied. The dan- 
gers, however, are very remote, as testified to by the 
German and French clinicians. When such dangers are 
feared, they can easily be overcome, as previously sug- 
gested, by the feeding of fresh fruit juices and vegetable 
preparations together with the milk diet. 

Does boiled milk offer advantages over raw milk? 
Boiled milk when properly handled is relatively free 
from pathogenic micro-organisms, and if the milk, which 
has been boiled, was clean milk, also from their toxic 
products. In raw milk we have a tendency even in clean 
milk to bacterial growth which causes souring, and which 
is not pathological, while when the lactic acid organisms 
are destroyed by boiling, in proper handling of boiled 
milk it will result in decomposition with its attendant 



COW'S MILK. 121 

dangers. Boiling in the home has the great advantage 
over commercial pasteurization and boiling in that, if 
the milk is raw and spoiled before it reaches the home, 
this can readily be detected by the housewife. While 
we know that certain pathogenic organisms may de- 
velop in the milk without giving evidence of their pres- 
ence, and cause formation of toxic bodies which are not 
removed by boiling in the home, the latter process still 
offers every advantage over commercial pasteurization. 
Boiling milk in the home will most certainly remove the 
dangers from infection with tuberculosis, scarlet fever, 
streptococcus sore throat, typhoid fever, dysentery, and 
many other milk-borne diseases. The advantages of 
boiled milk in the presence of indigestion and diarrhea 
have already been mentioned. The small, flocculent curd 
of the boiled milk is also rapidly and more easily digested 
than the large, tough casein curds of the raw milk. The 
hard bean-like protein curds are never seen in stools of 
the infant fed on milk which has been thoroughly boiled, 
although we have occasionally seen them in overfeeding 
with cow's milk which has been heated by the double 
boiler process. These latter cases, however, are ex- 
ceptions. 

Larger amounts and more concentrated mixtures of 
boiled milk can be fed than in feeding with raw milk; 
This is a distinct advantage in the beginning of the feed- 
ing of atrophic infants. This latter advantage is not to 
be overlooked. While the large percentage of healthy 
babies will apparently digest equally well raw and boiled 
milk within therapeutic limits, it will be found that most 
authors who do not resort to heating milk will, at least in 
some other way, modify the curd of raw cow's milk, 
either by simple dilution^ by the use of cereal waters or 



122 



INFANT FEEDING. 



an alkaline, such as lime water or sodium citrate. We 
agree with Brennemann in his statements that boiling 
commends itself as an excellent casein modifier, and that 
it effectually disposes of the majority of bacteriological 
problems when the milk is properly handled after boiling. 

Pasteurization versus Boiling. Pasteurization was 
first recommended because of the belief that boiled milk 
has scorbutic properties, which could not be laid at the 
door of pasteurized milk. The question of the relation- 
ship between boiled milk and scurvy has already been 
touched upon. Pasteurization in the home is not a very 
satisfactory process. Commercial pasteurization, even 
though properly carried out, is too distant from the 
probable time of consumption of the food to be a safe 
measure, unless the milk is properly handled after pas- 
teurization. The best argument presented by the advo- 
cates of pasteurization is that the milk is essentially a 
raw milk in so far as its physiological properties are 
concerned. 

Certified Milk versus Boiling. Clean certified milk ; 
properly handled, both before and after it reaches the 
home, and where the cost is not prohibitive, when well 
digested by the individual infant, still remains the ideal 
food for artificial feeding. When these requirements 
cannot be met, boiling in the home is the best method 
for preparation of milk for the infant. 

Various Methods of Boiling Milk. In our own work 
we have resorted in most cases to the heating of the 
milk in a double boiler. This has several advantages in 
that the milk is heated in a closed vessel, and has then a 
less pronounced flavor than when heated in open ves- 
sels, and causes but little pellicle formation, unless we 
have a very thin column of milk. To overcome this lat- 



COW'S MILK. 123 

ter, we therefore recommend the smallest double boiler 
which can be obtained, and which will at the same time 
hold all of the milk which is to be prepared. The milk 
mixture is put in the inner receptacle, cold, and the water 
in the outer vessel also cold. The double boiler is then 
placed on the stove, and allowed to remain until the 
water jn the outer vessel boils for six to eight minutes. 
While the milk heated in this manner forms .a very much 
finer and softer curd than that of raw milk, it is not as 
fine as that of milk boiled directly over the flame. How- 
ever, in most cases, it answers all purposes, and has 
the advantages above enumerated. In the presence of 
gastric and intestinal indigestion and allied conditions, 
the finer curd of the milk boiled directly over the flame 
may be more suitable ; and in exceptional cases, when 
boiling over the direct flame for three to five minutes does 
not give the desired result, milk boiled for 30 to 45 
minutes over the direct flame will ofifer further advan- 
tages, and this method is worthy of trial for temporary 
use. 



CHAPTER III. 

ADAPTATION OF MILK FOR INFANT 
FEEDING. 

From the foregoing it may be seen that there is no per- 
fect substitute for human milk in the feeding of the in- 
fant, and therefore every effort should be made to assist 
the mother in the nursing of her infant. 

Since all the attempts made to feed an infant on the 
food not primarily intended for this purpose are at- 
tempts at milk adaptation, we necessarily know that no 
single method can possibly meet the needs of all infants. 

And therefore it must be our object, first, to formulate 
our rules so as to make them safe and adaptable to the 
feeding of the majority of well babies, leaving the dis- 
cussion of exceptional and sick babies for further study. 
It must necessarily go without saying that the food 
recommended will be excessive for some and inadequate 
for others. Every organism has its individuality and its 
fixation coefficient, and every infant makes a different use 
of the food administered to it. All infants cannot, there- 
fore, be treated according to the same rule. 

While many excellent results have been reported with 
the various methods described for artificial feeding of in- 
fants, and some attempt has been made to place feeding 
on a scientific basis, we believe that we must concede 
that the methods are all more or less empirical, and the 
result will be in considerable degree dependent upon the 
wide range of food tolerance of the healthy infant. The 
successful physician must depend on the clinical ob- 
servation of the individual infant for the success of the 
(124) 



MILK FOR INFANT FEEDING. 125 

method of feeding which he is using. Every formula 
with which we start feeding should be looked upon in 
the light of an experiment, and the reaction of the infant 
to this feeding should be carefully studied. 

If these principles are borne in mind, many an ob- 
stacle to successful infant feeding will be avoided. 

We believe that the attempts toward ultra refinement 
of the infant's diet has led to considerable confusion, be- 
cause of the different conclusions of the various schools 
undertaking the work. Eventually, however, infant feed- 
ing will be placed on a thoroughly scientific basis. This, 
however, does not answer the pressing needs of to-day, 
which call for a safe and practical solution of the feed- 
ing problem for the feeding of the everyday baby in 
everyday life. The baby is so commonly receiving its 
feeding advice from food manufacturers ; and if feeding 
on one preparation is not successful, there is a rapid 
transition from one proprietary baby food to another, 
with untold detriment to the infant. In advancing the 
rules for feeding the normal healthy infant, with fur- 
ther suggestions for the underfed, on simple milk mix- 
tures with carbohydrates added, we desire to state that 
in our clinical experience we have "found them safe for 
the baby and practical for the physician, which latter is 
neither to be overlooked nor taken lightly. 

We claim nothing original for these feeding sugges- 
tions, as they represent the more common practice of the 
Continent, and America as well. We have, however, 
formulated the rules which govern the application of 
simple milk mixtures, with carbohydrates added, in such 
a way that their application becomes more practical. 
Knowing that the feeding advice which we are to receive 
and advise is founded on clinical experience, and that 



126 INFANT FEEDING. 

similarly good clinical results in feeding have been ob- 
tained by others by various methods of feeding, we be- 
lieve it advisable to briefly review the more popular 
methods of infant feeding as practised today. 

1. Undiluted Whole Milk. While undiluted milk 
has been used with varying degrees of success by some 
German and French pediatricians (of the latter Budin 
being the foremost advocate), it may be generally stated 
that, on the whole, it is not well borne before the fourth 
month of life. If whole boiled milk is used in the feed- 
ing of the very young infant, the size of the individual 
meal must be greatly restricted over that as recommended 
for diluted mixtures, so that it will not exceed the caloric 
requirements of the individual. Budin recommended 
that all whole milk fed to an infant should first be boiled, 
which causes the protein to be precipitated in the infant's 
stomach in the form of a fine curd. This can be fur- 
ther facilitated by the addition of pegnin or chymogen, 
which causes the formation of the fine curds before it is 
fed to the infant, with no recoagulation in the stomach.* 
Alkalinizing milk by the addition of sodium bicarbonate 
also results in the formation of fine curds. In some 
forms of vomiting, small quantities of a concentrated 
food will frequently be found of considerable value. As 
a routine measure of feeding, whole milk cannot be 
recommended. 

2. The Percentage Method or System of Feeding. 
This is frequently spoken of as the American method, or 
Rotch's method, because of the fact that Rotch, of Bos- 
ton, did much to popularize and systematize this method 
of feeding. Not only did he work out a system of 



* Brennemann, Archives of Pediatrics, 1917, 34, 81. 



MILK FOR INFANT FEEDING. 127 

formulae adapted to infants of varying ages and develop- 
ment, but he also was the means of establishing the first 
so-called public milk laboratory. The chief objections 
to this method, as originally described by Rotch, were 
its lack of flexibility and the difficulty of remembering the 
various formulae and their preparation. The followers of 
the Rotch school state that the percentage feeding, so- 
called, is not a method of feeding, but merely a method 
of calculation, and a means of obtaining relative accuracy 
in the preparation of infants' foods. They have sim- 
plified the method as originally applied, lengthened the 
feeding intervals, and, while still retaining some of the 
original ideas, have made the method far more practical. 

3. Top Milk Feeding. In this method a definite 
number of ounces of the upper part of the milk, which 
has stood for a number of hours, is used as the basis for 
preparing the mixture to be fed. 

, To successfully carry out top milk feeding, the per- 
centages of fat at various levels in 32 ounces (quart) of 
milk containing 4 per cent, of fat, and which has stood 
for six hours or longer, must be known : 

Upper 16 oz. has 7 per cent. fat. 
" 20 " " 6 " " '" 

<( ja a (( r (t a ti 

(1) This method endeavors to provide ample caloric 
values. In this respect the method may be regarded as 
successful. (2) There is the idea that casein is not 
very digestible, and that it is advantageous to feed casein 
in small quantities, making up the shortage in energy 
value of the mixture with fat. In the light of our pres- 
ent knowledge, however, we know that the casein of 
boiled or alkalinized milk, or when mechanically divided 



128 INFANT FEEDING. 

by the addition of cereals, is easily digested. (3) The 
attempt to produce a formula with the percentage of fat 
in the same proportion as is found in human milk, as 
well as larger amounts, which, however, frequently leads 
to fat indigestion, because of the greater difficulty experi- 
enced by many infants in handling large quantities of 
cow's milk fat. (4) The importance of the sugar and 
salt content of the mixture is underestimated. 

This method of feeding, nevertheless, has many ad- 
vocates, and we would advise that the above shortcom- 
ings of the method as originally described be given full 
consideration by those adopting this method of feeding. 



CHAPTER IV. 

MILK DILUTIONS WITH THE ADDITION 
OF CARBOHYDRATES. 

It has been our experience that about 90 per cent, of 
the infants that come under our observation for artificial 
feeding will tolerate a wide range of quantitative values 
in the components of the milk, i.e., fats, proteins, carbo- 
hydrates, and salts. And the simpler the first formula 
on which the baby is started, the easier we find it to 
meet its later needs for growth and development, by in- 
creasing or decreasing the individual elements in the diet. 
The first step of this method consists in the dilution of 
whole milk with water, thereby reducing all the ingredi- 
ents of the milk. When we compare such a dilution with 
human milk we find that when protein approximates that 
contained in breast milk, the fat is considerably reduced 
below that contained in the latter. This in practical feed- 
ing we find to be an advantage rather than a disadvan- 
tage, and if there be an indication for increasing the fat 
content of the formula this is easily accomplished by the 
addition of cream, or top milk, which is, however, usu- 
ally not necessary, as the deficiency in fat can usually be 
successfully compensated by adding sugar and starch 
to the formula. As a result of dilution, the salts, which 
are about three times as great in quantity in cow's milk, 
are reduced to more nearly the amounts contained in 
breast milk. We must, however, remember that there are 
qualitative differences in the salt content of the cow's 
milk dilution and human milk (page 144). 

Feeding should primarily be formulated to promote 

o . (129) 



130 INFANT FEEDING. 

normal growth and development, to supply energy for the 
body functions, to prevent disease; and, although of no 
lesser importance, feeding in disease should be given a 
secondary consideration in the study of this subject. 

The food must be given in such form that the infant 
may be able to digest it easily, to assimilate it, and 
to utilize its constituents for the purposes enumerated 
above. 

The following factors must be considered before esti- 
mating the composition and quantity of food for infant 
feeding. 

1. The clinical aspects — that is, the general well- 
being of the infant — must be given equal importance 
with the percentage and energy value of the food 
administered. 

2. Is there a normal gain in weight which an infant 
must show as a sign of full health? 

3. The qualitative and quantitative chemical composi- 
tion of the food, the number of calories available from 
the total administered, and the proportion of the total 
fixated in the body must be taken into calculation. 

The normal artificially fed infant should manifest the 
same clinical evidences of good health and progress as 
are seen in the breast-fed infant. It should be com- 
fortable, which he manifests in a happy disposition. He 
should be a good sleeper, and awaken regularly for his 
feedings, and there should be no more occasion for his 
crying than in the case of the breast-fed baby. His tem- 
perature should show maximum excursions of 1° to 2° F. 
daily. He should have large quantities of subcutaneous 
fat, and his muscular tissue should be well developed. 
The turgor of his tissues should be normal. The latter 
can be estimated by the eye and by palpation. The 



MILK DILUTIONS WITH CARBOHYDRATES. 131 

muscles may be taken between the fingers, and their firm- 
ness or softness estimated in this way. By raising a fold 
of the skin we may determine whether the panniculus 
adiposus is well developed. The stools, which of neces- 
sity must vary with the diet, are firmer and drier and 
much paler than those of the breast-fed infant, and he 
should pass one or two daily. Except in the presence of 
large amounts of carbohydrates, and more especially malt 
sugars, they are alkaline in reaction, and have a foul 
odor. 

Therefore, we see that the criterion of good health for 
the artificially fed infant depends on many things, 
which together make up the condition of the infant. And 
we again desire to emphasize that the impression of the 
general well-being of the infant is a much safer method 
of estimating its progress than a study of his weight- 
curve alone. 

We have learned to recognize the study of the infant's 
weight as one of the simplest and most reliable clinical 
factors in estimation of the infant's progress. And while 
of necessity the diet of different infants necessary to 
normal weight increases must vary within very consider- 
able limits, the scale offers information which is of in- 
estimable value. 

The following may be taken as working averages for 
comparative purposes, and the estimation of over- and 
under- weight in infants coming under observation. 

Average weight at birth 7 pounds (3200 Gm.) 

Average initial loss 10 ounces (300 Gm.) or about one-tenth 

of the body weight at birth. 
Birth weight regained usually by the fourteenth day. 
Weight is doubled at the end of the fifth month. 
Trebled at the end of the first year. 



132 



INFANT FEEDING. 



Average weekly gain during the first five months) should 

approximate 5 ounces (150 Gm.), during the remainder 

of first year 4 ounces (120 Gm.). 
Yearly gain during the second year 6 pounds (2727 Gm.). 
Gain during the third year 4.5 pounds (2000 Gm.). 
Gain from the fourth to the eighth year, 4 pounds annually 

(1800 Gm.). 
Gain from the eighth to the eleventh year, 6 pounds annually 

(2700 Gm.). 




Fig. 8. — Scale for weighing infants. 



An accurate scale is necessary equipment for proper 
infant feeding. Parents should be encouraged to pur- 
chase a balance scale with a large scoop. 

However, it is not sufficient to base the determination 
of the amount of food on the weight of the baby alone, 
since two infants of the same weight may have decidedly 
different nutritional requirements, dependent upon vari- 
ous factors. The fat baby requires less food per pound 
than the thin baby — the overfed less than the underfed 
infant; and the sick baby must of necessity be fed within 
its limits of tolerance during the acute part of its illness, 



MILK DILUTIONS WITH CARBOHYDRATES. 133 

and the body losses must be compensated by increases in 
the diet beyond those which we have learned to consider 
as the normal feedings per pound body weight, as its 
tolerance for food permits during convalescence. 

A healthy infant should, therefore, show a regular gain 
within certain limitations. It is not absolutely necessary 
for an infant to add to its body weight every day, as daily 
irregularities are rather the rule than the exception. The 
relation of the time of weighing to the feeding, defeca- 
tion, and urination are factors which must always be 
taken into consideration. Therefore under normal condi- 
tions it is sufficient to weigh the infant once a week. It 
is especially wise to impress this upon a nervous mother. 

Further, we must not forget that the weight curve of 
the nursing infant and that of the artificially fed infant 
differ widely, so that they cannot be compared directly., 
The artificially fed infant, although in the beginning 
gaining less than the breast-fed infant, in the course of a 
year reaches the same weight as the breast-fed infant, 
who at first showed larger gains, but later lagged some- 
what in its gains. Much more important than the weight 
itself is the rising series of successive weight figures. 

The clinical aspects, that is, the general well-being of 
the infant must be given equal importance with the per- 
centage and energy value of the formula. In a consider- 
ation of the latter two important factors in successful 
feeding, the chemical composition must be considered of 
equal importance with the caloric value. Otherwise one 
meets with profound disturbances due to feeding of in- 
sufficient or excessive amounts of the components of the 
diet, difficult of interpretation. 

It may therefore be stated that the infant must be fed 
amounts of fat, protein, carbohydrates, and salts and 



134 INFANT FEEDING. 

water suitable to its constitution, age, and physical de- 
velopment, and that these ingredients should be in proper 
proportion and of sufficient quantity to meet the caloric 
requirements of its tissues for growth and development. 
Again, we must not overlook the fact that the constitu- 
ents of the diet must be in such form as to allow of nor- 
mal digestion and assimilation. 

We have spoken of the wide range of tolerance of in- 
fants to their foods, and have mentioned that this, in all 
probability, accounts to a very great degree for the fact 
that so many men have been successful in the feeding of 
infants on a variety of mixtures which varied greatly 
both quantitatively and qualitatively. There is in all 
probability another factor which is important in explain- 
ing these successes, namely, the fact that to a certain ex- 
tent fats, carbohydrates, and proteins are interchange- 
able in their metabolic functions. 

Proteins. After passing through the intestinal wall 
proteins Jiave three functions to perform: (1) to replace 
used protein (lost through urine, sweat, digestive juices, 
cell destruction, etc.) ; (2) to satisfy cell growth, which 
would be impossible without proteins; (3) to furnish 
fuel for part of the dynamic loss (fats and carbohydrates 
are the natural fuel, the protein combustion being 
incidental only). 

There is three times as much protein in cow's milk as 
in human milk. The reason for this is obvious, when 
w r e recall that the ratio of the growth of the calf to that 
of the infant is about as 2 to 1. Furthermore, the protein 
in cow's milk consists chiefly of casein (3.02 per cent.) 
and little lactalbumin (0.53 per cent.), while human milk 
contains 0.59 per cent, of casein and 1.23 per cent, of 
lactalbumin. , 



MILK DILUTIONS WITH CARBOHYDRATES. 135 

The proteins are characterized by containing nitrogen. 
If the nitrogen is determined in the food eaten during the 
period of the experiment, it is evident that a balance may 
be struck which will determine whether the body is re- 
ceiving in the food as much protein nitrogen as it is 
metabolizing and eliminating in the excreta. If there is 
a plus balance in favor of the food, it is evident that the 
body is laying on or storing protein, while if the balance 
is minus, the body must be losing protein. During the 
period of growth, in convalescence, etc., the body does 
store protein, and under these conditions the balance is in 
favor of the food nitrogen. ■ 

It is important also to bear in mind that nitrogen or 
protein equilibrium may be established at different levels 
in order to explain the good feeding results with what 
may be an excessive protein diet. That is, an infant who 
has been receiving 1.5 Gm. of protein per Kg., and who 
has excreted the greater part thereof, retaining only such 
portion as is needed for the body growth, will, upon 
being fed larger quantities, retain only a similar amount 
for body growth, excreting the difference in the urine, 
sweat, and feces. The true cell life does not depend on 
what has been ingested, absorbed and temporarily fixated, 
to be eliminated soon afterwards, but on the constant and 
stable fixation. The body may become adapted to over- 
feeding and overtaxation, but this is usually of only a 
short duration, and the excretion of the oversupply is 
never long delayed. Experimentally, it is found that 
there is a certain low limit of protein which just suffices 
to maintain nitrogen equilibrium. Rubner found that 
when 5 per cent, of the total energy intake was in protein 
that it was sufficient for maintenance, and that even 4 
per cent, was sufficient to supply its actual need when 



136 INFANT FEEDING. 

amply supplied with carbohydrate. However, 7 per cent, 
was necessary to keep up the normal growth. 

Examination of the dietaries of civilized races shows 
that, on the average, 100 to 120 Gm. of protein are used 
daily by an adult man. A variable portion of this amount 
passes into feces in undigested form, but we may assume 
that about 100 to 105 Gm>. are absorbed, and actually 
metabolized in the body. If we take into account the 
weight of the body, this amount of protein may be esti- 
mated as equivalent in round number to 1.5 Gm. of pro- 
tein, or 0.23 Gm. nitrogen, per kilogram of body weight. 
Chittenden believes that the daily quota of protein per 
kilogram of body weight may be reduced to one-half this 
quantity, from 1.5 Gm. to 0.75 Gm. of protein, or 0.12 
Gm. of nitrogen, per kilogram body weight. 

If the body can be kept in good condition upon 0.75 
Gm. per kilogram per day, will an ingestion of more than 
this (say twice as much) prove injurious or beneficial or 
indifferent to the body? The full and satisfactory 
answer to this question must be deferred until more ex- 
perience is obtained. The newer conceptions in regard 
to the digestion and nutritive history of the protein foods 
seem to favor the adoption of a low protein diet. 
Mankind, when left to the guidance of the natural appe- 
tites, has always, when possible, adopted the high pro- 
tein level of 90 to 100 Gm. per day. That mankind has 
made a mistake in adopting the higher protein level can 
hardly be claimed on the basis of our present knowledge. 

The chief demands for protein are to compensate for 
wear and tear, and to provide for growth. 

Sugars and starches, when added to a diet sufficient to 
meet an infant's needs, will, temporarily at least, cause 
a greater nitrogen retention. Fats have little or no such 



MILK DILUTIONS WITH CARBOHYDRATES. 137 

influence. Nitrogen to be retained must be built up into 
living protoplasm, and to accomplish this salts must be 
available. Unless they are present, the nitrogen is again 
excreted. Approximately 1.7 Gm. of ash are retained 
for each 1 Gm. of nitrogen (Howland), or 0.3 Gm. of 
ash for each 1 Gm. of protein. 

Hoobler believes that the protein needs of the infant 
are supplied when 7 per cent, of its caloric needs is fur- 
nished in protein calories, and states that three-fourths of 
an ounce 'of whole or skim milk, or 1.3 Gm. of Protein 
per kilogram (0.6 Gm. per pound) body weight is 
sufficient to meet these needs. To make up the deficiency 
in the caloric needs, he adds for each ounce of whole 
milk one-third of an ounce of sugar or cereal.. 

Rubner was able to promote normal growth when 0.7 
per cent, of the total energy intake was in proteins. 

Cowie finds the protein requirement in a two- to 
twelve-months infant to average 2.4 Gm. per kilogram 
(1.1 Gm. per pound). 

Dunn states that 1.0 Gm. to 1.5 Gm. of protein daily 
per kilogram (.45-. 7 Gm. per pound) of body weight is 
necessary for the normal infant. 

Camerer states the following requirements for each 
kilogram of body weight in a child between 2 and 4 
years of age: proteins, 3.6 Gm. ; fat, 3.1 Gm. ; carbohy- 
drates, 9.2 Gm. ; and water, 75.3 Gm. 

It has been our custom to feed approximately 1.5 
ounces of milk to a pound of body weight to the healthy 
normal infant, which would represent 1.5 Gm. of protein 
per pound of body weight. (3.3 Gm. per kilogram.) 

Notwithstanding what has been said on theoretical and 
experimental studies of the protein needs of the arti- 
ficially fed infant as compared with the amount of pro- 



138 INFANT FEEDING. 

tein as received by the breast-fed infant, it must be 
granted that casein, the chief protein of cow's milk, as 
given in ordinary dilutions to the infants is sufficient to 
cover entirely the protein needs of the infant, and that 
its excess rarely causes nutritional disturbances when 
the tendency to large curd formation is prevented by 
boiling or alkalinizing the milk. 

We have therefore continued to use the protein as 
contained in 1.5 ounces of milk per each pound of body 
weight of the normal infant, and in the underfed we 
have not hesitated to increase this quantity to an amount 
equal to 2 or even 2.5 ounces per pound, thereby approxi- 
mating 1.5 ounces per pound of what the baby should 
weigh for its age. Increases of milk in the diet must be 
gradual, the additions being guided by the child's ability 
to handle the food. From what has been stated, it may 
be inferred that it is wise to establish the protein content 
in a diet which may then be supplemented by fats, carbo- 
hydrates, and salts, because protein is the tissue builder 
and must necessarily be a basic constituent of all diets. 

Fats. Fats are necessary to normal growth and 
nutrition of the human body. But they to a greater ex- 
tent than the other food elements can be replaced by 
proteins and sugars, more especially the latter. This ex- 
plains the fact that infants fed on low fat mixtures, more 
especially proprietary foods, such as condensed milk, will 
continue to gain in weight. However, such development 
cannot be considered as normal. 

Fats furnish part of the heat energy necessary to main- 
tain the body temperature. They are stored as a reserve 
food. The fat is a protein saver, and when supplied in 
proper amount but little protein is used for the produc- 



MILK DILUTIONS WITH CARBOHYDRATES. 139 

tion of animal heat, thereby allowing for greater protein 
retention for the growth of the body tissues. 

Under normal conditions, the average infant will digest 
from 2 to 3.5 per cent, of fats. However, some infants 
digest fat badly, and when a fat intolerance is once estab- 
lished it is overcome only with great difficulty. In such 
cases it is necessary to throw the burden of furnishing 
the extra food necessary on the carbohydrates ; and car- 
bohydrates in large quantities are unsafe food for the 
infant. Such a catastrophe should be avoided, as infants 
receiving an insufficient amount of fat rarely thrive satis- 
factorily. We should therefore aim to stay within safe 
limits. And it has been our experience that most infants 
will thrive well on the amount of fat furnished by the 
use of 1.5 to 2.0 ounces of whole milk per pound body 
weight. When moderate quantities of fat are fed, we 
avoid the acute clinical picture of fat overfeeding asso- 
ciated with vomiting and diarrhea, and not infrequently a 
high temperature, and occasionally convulsions. On the 
other hand, the moderate quantity of fat contained in the 
diet necessitates a high percentage of carbohydrate feed- 
ing, which in turn avoids the so-called fat-soap stools, 
with their tendency to rob the body of an excessive 
amount of calcium and magnesium. For the ■ formation 
of a fat-soap stool it is necessary that we have an insuffi- 
ciency of carbohydrates and a relative excess of proteins, 
as putrefaction is necessary for the production of these 
stools, while fermentation opposes their formation. And 
in the presence of excessive fermentation the putrefac- 
tion is limited. 

It may therefore be stated that while the tolerance for 
fat of cow's milk varies greatly in different individuals, 
most infants, however, will digest and assimilate 1.5 to 



140 INFANT FEEDING. 

2.0 Gm. of fat per pound body weight daily, (3.3-4.4 Gm. 
per kilogram) which is the quantity represented in 1.25 
to 2.00 ounces of average cow's milk. This quantity will 
also supply the body needs for growth and development, 
when associated with a sufficient carbohydrate. 

Carbohydrates. They are used chiefly to supply 
heat and energy, to supply in part material for fat foun- 
dation, thereby replacing in part the fat waste. Because 
of their high caloric value they supply a large amount of 
energy. They are efficient sparers of protein, and will 
supply energy in case of fat insufficiency in the diet. 
Synthetically, they are converted into glycogen in the 
body. Fat is formed from sugar by the subcutaneous 
cells, which are especially adapted to this function. 
Sugar is reduced to C0 2 and water, which may be meas- 
ured by the respiratory metabolism. Normally, sugar is 
absorbed from the small intestine in greater part, and is 
not found in the feces. If absorbed in sufficient quantity, 
they will cause a rapid increase in weight. When insuffi- 
cient carbohydrate is supplied to the body, it is obtained 
by breaking down the body protein. 

In general, infants have a very high carbohydrate tol- 
erance — much higher than the adult — and even infants 
suffering from certain forms of nutritional disturbance 
may retain their ability to metabolize sugar, even though 
it may have been reduced for fat and proteins. Some 
infants do not handle sugar well, and among these 
are certain forms of gastro-intestinal disturbances, 
eczema, etc. 

During recent years much has been written on the 
superiority of one form of carbohydrate over the other. 
We can practically exclude the monosaccharides in the 
consideration of the subject, and speak only of the di- 



MILK DILUTIONS WITH CARBOHYDRATES. 141 

saccharides, of which lactose, saccharose (cane-sugar), 
and maltose are the ones used in infant feeding, of the 
polysaccharides, as represented by the cereal flours and 
dextrin, and last, of the mixture of disaccharides and 
polysaccharides, together with other substances, these 
mixtures being represented by the various infant foods 
on the market. 

Cane and Milk Sugars. Of recent years there has 
been a considerable discussion on the comparative nutri- 
tive value of milk-sugar (lactose) and cane-sugar 
(saccharose. In our own experience we have found little 
to recommend one over the other in so far as their 
nutritive value and the limit of tolerance is concerned, 
except as we have seen a laxative effect from the use 
of lactose, which is usually not present with the same 
quantities by weight of saccharose. This is, however, 
not seen in all infants. 

Cane sugar will answer the needs of most infants. 
For practical purposes the following quantities of sugar 
in addition to that contained in the milk will meet the 
carbohydrate requirements. 

1. Normal full weight infants one-tenth ounce by 
weight of sugar for each pound of body weight (3 grams 
for each pound). 

Carbohydrate needs beyond that furnished by one and 
one-half ounces of sugar should be supplied by well 
cooked cereal waters, because of the danger of sugar 
indigestion. (See mixed diet page 156.) 

The total carbohydrates (sugar contained in the milk, 
sugar added to the milk, and cereal, if used), should 
average from one-eighth to one-fifth ounces, (4 to 6 
grams) per pound body weight a day. One and one- 



142 INFANT FEEDING. 

half ounces of milk, averaging 4.5 per cent, carbohydrate 
furnishes 2 grams of lactose. 

2. In underweight infants the amount of sugar to be 
added must frequently be calculated on the basis of 
the normal average weight of the healthy infant of 
the same age (see page 132). 

Precautions to be Heeded in the Addition of Carbo- 
hydrates to the Infant's Diet: 

1. Infants who have been on a low sugar diet should 
be accustomed to the change by gradual increase of the 
sugar content of their food. 

2. In underweight infants the amount of sugar to 
start with should be calculated on the basis of their 
present weight. The quantity of sugar needed for a 
full weight infant of the same age should then be ap- 
proximated as rapidly as the sugar tolerance permits. 

3. In changing from one kind of sugar to another, it 
is always a safe rule to reduce the quantity for a few 
days, further increases being governed by the infant's 
tolerance. 

4. It should be remembered that in some infants the 
disaccharides when fed in full amounts are liable to 
produce digestive disturbances. In these infants the 
sugar in part at least must be replaced by polysaccharides 
in the form of cereal flours and cereals. 

Maltose and Dextrin Compounds can frequently be 
added to the diet to advantage in the presence of sta- 
tionary weight, because they can be added to the mix- 
ture in quantities approximating one-eighth of an ounce 
(4 grams) for every pound normal weight, when indi- 
cated. It must, however, be remembered that their 
action on the bowels varies greatly depending upon their 
maltose, dextrin and alkali content. Thus we find that 



MILK DILUTIONS WITH CARBOHYDRATES. 143 

those of the proprietary foods containing a considerable 
percentage of dextrin, in the absence of the potassium 
salt, are constipating (Horlick's malt food, Mead's dex- 
trimaltose No. 1 and No. 2), while those with a higher 
maltose content together with potassium carbonate (Bor- 
cherdt's dri malt soup and Mead's Dextrimaltose No. 3) 
or with potassium bicarbonate (Mellin's food) are 
laxative. 

Cereal Flours. They can be added to the diet of 
most infants early in life in quantities varying from 0.5 
to 1.0 Gm. of the flour for each pound of body weight 
made into a gruel. Such an addition to the food fre- 
quently results in rapid weight increases, and general 
improvement of the infant. In older infants, cooked 
cereals may be used in place of the starch solutions. We 
have reason to believe from clinical experience that the 
flours made from unheated cereals have a decided advan- 
tage over the dextrinized flours on the market. Whether 
this is due to vitamines contained in the former or to some 
other distinctive property we are unable to state. The 
cereals also have a decided influence on the calcium 
and magnesium balance. The cereals cause retention of 
these salts, which may have a favorable influence on the 
weight. 

Salts. Salts are necessary in digestion, and in every 
step of metabolism, from absorption to excretion and 
secretion. The role of salts in both normal and path- 
ological conditions has been given constantly increasing 
importance in the last few years. 

Human milk contains 0.2 Gm. of ash in 100 mils, and 
cow's milk 0.75 Gm. of ash in 100 mils. The difference 
in percentage in the human and in the cow's milk is 
equalized by the body using only what is necessary for its 



144 INFANT FEEDING. 

life and growth. The salts are absolutely necessary for 
the life of the organism. 

All the salts except those of iron are found in larger 
amounts in whole cow's milk than in human milk. In 
general, cow's milk contains relatively a very large 
amount of calcium phosphate, while the proportion of iron 
in cow's milk as compared with human milk is relatively 
small. There is a great difference in the form in which 
phosphorus is present in human and in cow's milk. In 
human milk three-quarters of the phosphorus is in or- 
ganic combination, while in cow's milk only one-quarter 
is in organic combination. The iron in neither human 
milk nor in cow's milk is sufficient to meet the demands 
in the first year of life ; the infant must depend on the iron 
stored during fetal life. 

The f ollow 7 ing table gives the percentages of the differ- 
ent salts in 100 parts of ash of human and of cow's 
milk. 

CaO MgO P 2 5 Na 2 K 2 C! Fe 

Human milk .... 23.3 3.7 16.6 72 28.3 16.5 .00015* 
Cow's milk 23.5 2.8 26.5 72 24.9 13.6 .00007* 

Grams of salts per 100 c.c, of milk. 

CaO MgO P 2 5 Na 2 K 2 CI Fe 

Human milk . . .0458 .0074 .0345 .0132 .0609 .0358 .00017* 
Cow's milk 172 .02 .2437 .0465 .1885 .082 .00007t 

In all the constituents except P2O5 and iron, the per- 
centages of the different salts in the two milks are prac- 
tically the same. The higher proportion of phosphorus 
in cow's milk is due to the large amount of the casein. 
Though the proportions of the different salts of the 



'♦Holt: Amer. Jour, of Dis. of Child., Vol. x, 1915. 
t Langstein-Meyer : Weisbaden, Verlag von J. F. Bergman, 
1914, p. 22. 



MILK DILUTIONS WITH CARBOHYDRATES. 145 

ash in cow's milk are so nearly those of human milk, the 
amount in cow's milk is about three and a half times 
as great. Unless, therefore, cow's milk has been diluted 
with more than twice its volume, the amount of these 
inorganic constituents, furnished to the infant is equal 
to that which he receives in human milk (Holt). 
Human milk contains about twice as much iron as cow's 
milk, and dilution of cow's milk results in a decrease 
in the iron content, which must not be carried too far 
unless supplemented by other iron-containing food. 

The infant receiving undiluted cow's milk, with its 
greater salt contents, lives on a higher plane of mineral 
metabolism than does the one receiving the breast milk. 
He absorbs 60 per cent, of the total ash, and retains only 
about 15 per cent., while the breast-fed infant utilizes to 
the full his opportunities, and absorbs 80 per cent, of 
the ash, and retains 40 to 50 per cent. In the majority 
of infants this excessive salt intake undoubtedly does no 
harm ; the surplus is not absorbed, or is merely eliminated. 

"Sodium and potassium are usually well retained, un- 
less severe diarrhea is present, or there is an excess of 
fat or of sugar in the diet. Under such circumstances 
they are lost, and the loss is badly borne, and cannot in- 
definitely be continued. When all available alkalies have 
been drawn on, the infant breaks down his own tissue 
to furnish more of these substances, w T hich is an explana- 
tion, for a part at least, of the excessive nitrogen excre- 
tion under such conditions. When diarrhea ceases, and 
the intake is sufficient, a positive balance is rapidly 
instituted. 

"The metabolism of calcium has been largely studied, 
on account of its close relationship to rickets and tetany. 
Calcium is so largely excreted by the bowel that it is ini- 

10. 



146 INFANT FEEDING. 

possible to say how much is absorbed, plays part in the 
organism, and is then excreted by the intestine, either be- 
cause it is in excess, or because (as in the case of rickets) 
the body cannot utilize it. This is also true of mag- 
nesium, and to a much less extent of sodium and potas- 
sium" (Howland). 

The salts are necessary for building up of the body tis- 
sue, and each gram of protein retained and built into 
body tissue requires approximately one-third of a gram 
oi ash. 

Water. The quantity of water necessary for the in- 
fant is not only of theoretical, but also of vast practical 
importance. There are many breast-fed infants who ob- 
tain a food which is very rich in other nutritive sub- 
stances, but contains only a small amount of water. 
These infants may not gain well in weight unless water 
is added. And, besides that, in sick infants it is occa- 
sionally necessary to feed them (especially in cases of 
vomiting, anorexia, infections) with concentrated food, 
and in these cases the total water intake necessary must 
not be lost sight of. 

In regard to water retention Meyer* found three 
classes of cases: (1) those in which there was a de- 
crease in weight when the food was concentrated, and 
the weight increased only after addition of water; (2) 
those where the weight remained the same on a concen- 
trated food, and there was .an increase after the addition 
of water; and (3) those in which the addition of water 
made no difference, but who did well on a concentrated 
food. He found that the water need decreased with in- 
creasing age — that on artificial food the water needs 



* L. F. Meyer, Zschrft. f . Khlk. 1912, 5, 1. 



MILK DILUTIONS WITH CARBOHYDRATES. 147 

were 89 Gm. per Kg. body weight in twenty-four hours 
at the beginning, and 80 Gm. at the end of the first year; 
while in breast-fed infants the water need amounted to 
134 Gm. to 140 Gm. per Kg. in twenty- four hours. 

Water is absolutely necessary for life, and manifesta- 
tions of life are impossible without water. The lack of 
or inadequacy of water are much more dangerous to the 
infant than a corresponding deficiency in the food. Ex- 
cess of water, however, exerts also an unfavorable influ- 
ence on the organism. Immunity is considerably de- 
pendent on the physiological water content of the body. 

Estimation of the Caloric Contents of the Food as a 
Check on Over- and Under- feeding. Calorimetric 
estimations of the diet must be considered only as a check 
on under- and over- feeding, and not as a method of 
feeding. In the infant whose diet usually consists of 
milk or its constituents and sugar and cereal flours, this 
is a very simple matter. It should, however, be remem- 
bered that there are considerable variations in the caloric 
requirements of normal babies. The fat and well-nour- 
ished infant will require less food to maintain its body 
heat than the emaciated one., The sick baby will rarely 
be able to digest its full needs as estimated by its body 
weight. Therefore as in every other phase of infant 
feeding, the individual infant must be given primary 
consideration. It must be remembered that the nutri- 
tion of the baby depends upon the quantity of the food 
assimilated, and not upon the quantity ingested. Less 
food is being absorbed and utilized in the infant with a 
deficient power of digestion, and overfeeding will re- 
tard the infant's progress. A comparative estimate of 
the infant's diet, with a theoretical minimum, is of special 
value in cases of doubt as to whether the retarded prog- 



148 INFANT FEEDING. 

ress is due to insufficient food or defective digestion and 
assimilation. 

Under this system the physician reckons the minimum 
daily caloric requirements, either from the present 
weight of the baby or what it should weigh in health, 
and then chooses the food necessary to meet this re- 
quirement, bearing in mind that the fat, carbohydrate and 
protein contents of the diet must not only meet the 
caloric requirements, but also be properly proportioned, 
so as to contain the proper number of grams of each of 
the constituents to meet the infant's needs for growth 
and development. 

Heubner and Rubner gave us the first definite estimates 
as to the caloric needs. They found that the average 
healthy infant after birth requires on the average 100 
calories per kilogram body weight, from six months to 
the end of the first year — approximately 85 calories per 
kilogram body weight — and that 70 calories per kilogram 
body weight is the energy quotient on which a baby would 
maintain a weight equilibrium. 

Dunn places this minimum caloric requirement for 
artificially fed infants as follows: 

Birth to 6 months . . . 120 cal. per Kg. (55 cal. per pound) 

6 to 12 months 100 " " " (45 " " " ) 

12 to 24 months 90 " " " (40 " " " ) 

Dennett* gives the following figures: 

Fat infants over 4 months of age . . 40 to 45 cal. per pound 
Average infants under 4 months of 

age and moderately thin infants of 

any age 50 " 55 " " 

Emaciated infants (varying with the 

degree of emaciation) 60 " 65 " " 



* Infant Feeding, J. B. Lippincott Co., Philadelphia, page 58. 



MILK DILUTIONS WITH CARBOHYDRATES. 149 

Brady* gives the following figures as his experience 
with institutional children: 50 to 55 calories for each 
pound during the first 6 to 8 months of life. 

Our own experience coincides with those of Dennett 
and Brady in that we find that the figures of Heubner do 
not meet the requirements of any except the well-nour- 
ished infants. Underfed infants not suffering from de- 
composition (marasmus) must be fed food of a higher 
caloric value per pound body weight than the normal in- 
fants, and while such infants must be fed minimal quan- 
tities when first seen, for a proper gain in weight their 
normal weight must be estimated and their diet gradually 
approximated to the needs of the weight that they should 
normally have. 

Average infants under 

2 months of age . . 30 to 45 cal. per lb ( 65 to 100 per Kg.) 
Average infants over 

2 months of age ..45 " 55 " " " (100 "120 " " ) 
Premature and thin 

infants under 2 

months of age 50 to 65 cal. per lb (110 to 140 per Kg.) 

Thin infants older 

than 2 months, de- 
pending upon their 

general condition . 55 " 70 " " " (120 " 150 " " ) 

During the first few weeks of life of the artificially fed 
infant it is usually difficult to approximate these figures 
(seep. 159). 

Increases in quantity of food should always be gradual, 
especially in the presence of malnutrition, and the infant 
carefully observed, and increases made only as the toler- 
ance for food permits. 



*J. M. Brady, Institutional Care of Infants, Archives of Ped., 
1917,34,356. 



150 INFANT FEEDING. 

Estimation of the caloric contents of the food is not a 
feeding method and should be used only as a check on 
over- and under- feeding, the scale, stool, and general 
condition, and particularly the disposition of the infant, 
being the ultimate guide for dietetic changes. 

Energy quotient is the number of calories which the 
infant is getting per pound or per kilogram of body 
weight. To determine the energy quotient of the diet 
multiply the number of ounces of each food ingredient of 
the food mixture by their caloric values, add the products 
and divide the sum by the number of pounds or kilo- 
grams of the baby's weight. 

Caloric Values of 1 oz. (30 Gm.) of Various Foods. 

Calories 

Cow's milk 21 

Human milk 21 

16 per cent, cream 54 

Skim milk 11 

Buttermilk 11 

Buttermilk mixture 21 

Albumin milk 12 

Chymogen milk 21 

Keller's malt soup 25 

Cane-sugar (by weight) 120 

Maltose-dextrin compounds (average) 110 

Malt-soup extract, dry, by weight 90 

" by measure 132 

Flour, by weight 100 

Cereal waters (1 oz. cereal to quart) 3 

Practical Application of Milk Dilutions with Addi- 
tion of Carbohydrates in Infant Feeding. In the appli- 
cation of the rules for the feeding of normal, healthy 
infants, it must be remembered that each infant must be 
fed to meet its individual requirements, and the rules 
modified 50 as to meet the demands of the individual 



MILK DILUTIONS WITH CARBOHYDRATES. 151 

baby. If milk dilutions, with the addition of carbohy- 
drates are used, the simplest and most natural standard 
would be one that would tell us how much milk and car- 
bohydrates per pound or per kilogram body weight the 
baby should get. To be exact we should express, or at 
least be aware, of the number of grams of proteins, fats, 
carbohydrates and salts that the infant is receiving for 
each pound of its body weight. We believe that if statis- 
tics on infant feeding were collected on this basis rather 
than in percentages of the ingredients in the milk mix- 
tures (the total mixture being of such variable quantity) 
the collected data zvould be far more valuable as a basis 
for future work in infant feeding. 

In every instance the general health of the infant is of 
the greatest importance in estimating its capacity for as- 
similating the diet. 

To meet protein and fat requirements, the average nor- 
mal infant will require each day a minimum of 1^2 
ounces (45 mils) of cow's milk per pound of body 
weight, exclusive of the sugar and starch which are 
added in preparation of the mixture. 

Practical experience has taught us that infants under 
five months of age will frequently require amounts ap- 
proximating 2 ounces (60 mils) of cow's milk per pound 
body weight, except during the first few weeks of life, 
when smaller quantities of whole or skim milk are indi- 
cated (see p. 159). With the institution of a mixed diet, 
the infant thrives with less milk per pound body weight. 

In beginning feeding with cow's milk, mixtures must 
always be started as weak formulae, more often using 
only 1 ounce (30 mils) of cow's milk to a pound body 
weight, gradually increasing the strength to meet the 
infant's needs. 



152 INFANT FEEDING. 

Underweight infants should at first be fed according 
to their present weight, gradually increasing the strength 
of the mixture as rapidly as consistent with the baby's 
ability to handle the diet, and thus approximating the 
needs of a full weight baby of the same age. These 
babies will frequently take over 2 ounces (60 mils) of 
milk per pound body weight. 

Number of Feedings in Twenty-four Hours. Three- 
hour intervals at the start, with 7 feedings in twenty- 
four hours, for the first month (6-9-12-3-6-10-2), 6 feed- 
ings during the second and the third month (6-9-12-3- 
6-10), 5 feedings by the fourth to the fifth months (6-10- 
2-6-10), according to the individual needs of the child. 

Premature and delicate infants with a tendency to 
vomit are exceptions, and may be fed smaller amounts at 
more frequent intervals, even two hours, if indicated. 
Catheter feeding may be necessary, in which case the 
longer interval will usually answer. 

Amounts at Each Feeding. From birth to the fifth 
month the average healthy infant may be satisfied with an 
amount of food approximating 2 ounces more per feed- 
ing than the infant is months old ( 1 month, 3 ounces ; 2 
months, 4 ounces; 3 months, 5 ounces; etc.). Exception- 
ally, infants cannot take this amount at each feeding, and 
when vomiting is the result of overfeeding, the quantity 
can be reduced and an extra meal substituted. 

After the fourth month the average infant will take 
daily 1 quart of the food mixture. 

When more than 1 quart of milk mixture is needed to 
properly nourish the infant, we have reached the age 
when a mixed diet should be instituted. 

By the sixth month four meals of 8 ounces each of 



MILK DILUTIONS WITH CARBOHYDRATES. 153 

milk mixture may be given, and a fifth meal of broth 
and vegetables (see rules for mixed diet, p. 156). 

Water to be Added. In our own experience we have 
found that a concentrated milk mixture does not disturb 
the infant's digestion when the milk is boiled or alkalin- 
ized by sodium citrate, sodium bicarbonate, or lime- 
water. The amount of water is calculated by multiplying 
the number of feedings by the amount of each feeding, 
and subtracting the milk to be given. 

Example: Baby aged 3 months should receive 5 feed- 
ings, 5 ounces each (age in months plus 2) or a total of 
25 ounces for the day. Subtracting 16.5 ounces (11 
pounds body weight and 1.5 ounces of milk for each 
pound) gives us 8.5 ounces as amount of water to be added. 

Carbohydrates to be added. Having the necessary 
amount of milk and water, we ascertain the carbohy- 
drate to be added. 

Cane sugar answers our requirement for most cases. 

Milk sugar acts as a laxative in many infants. Unless 
the laxative effect is desirable, it has no advantages. 

Maltose and dextrin compounds are acceptable to the 
infant's digestion in relatively larger quantities. They 
are not as sweet as cane sugar. They are of practical 
value when large amounts of cane or milk are not well 
taken. Because of their varying maltose, dextrin and 
alkali content some are constipating and others are 
laxative. This must be given due consideration in their 
selection (see pages 143, 277 and 278). 

Cane and milk sugar are added in such quantities that 
the normal infant in its food mixture receives a total of 
from 4 to 6 grams of carbohydrates per pound of body 
weight per day, including that contained in the milk in 
the mixture. As one and one-half ounces of milk con- 
tains approximately 2 grams of lactose it will be neces- 



154 INFANT FEEDING. 

sary to add from 2 to 4 grams of carbohydrates for 
each pound of body weight to the diet besides that con- 
tained in the milk. The needs of the average normal 
infant in the first months are usually satisfied by the 
addition of one-tenth of an ounce (3 grams) of cane 
sugar per pound body weight to the milk and the water 
in the mixture. 

When using maltose-dextrin compounds somewhat 
larger quantities can often be fed to advantage. One- 
eighth ounce (4 grams) per pound are usually well taken. 

We do not hesitate to add cereal water to the diet 
after the infant is one month old, and find it especially 
valuable in those cases in which we are feeding cane- 
sugar, and in which the infant takes a dislike to its food 
because of the intense sweetness of the mixture. One- 
sixtieth to one-thirtieth of an ounce (0.5 to 1.0 gram) 
of starch for each pound of body weight may be added 
to the mixture. This is best given in the form of cereal 
waters or well cooked cereals. 

In underweight infants the amount of sugar to start 
with should be calculated on the basis of the present 
weight, approximating the quantity needed for a full 
weight infant as rapidly as the sugar tolerance permits. 

The following table gives equivalents of 1 ounce by 
weight and the domestic measures of carbohydrates used 
in artificial feeding of infants : 

By By Table- Dessert- Tea- 

weight measure spoonfuls spoonfuls spoonfuls 

leveled with a knife. 



Cane-sugar '. 


oz. 30 Gms. 


1.00 oz. 2 


3 


6 


Milk-sugar 


" " " 


1.50 ' 


3 


4.5 


9 


Maltose-dextrin . 




1.50 ' 


3 


4.5 


9 


Flour (wheat) . . '. 


a it it 


2.25 ' 


5 


7.5 


15 


Flour (barley) . 


tt a it 


1.50 ' 


3 


4.5 


9 


Barley (pearl) . 


u a a 


2.50 ' 


5 


8 


15 


Oats (rolled) .. ] 


<( a a 


2.50 ' 


5 


8 


15 



1 tablespoonful = 1.5 dessertspoonfuls — 3 teaspoonfuls. 



MILK DILUTIONS WITH CARBOHYDRATES. 155 

To Break the Curd to Assist Digestion of Cow's 
Milk. Many infants can digest raw cow's milk. When 
not well taken, the tendency to formation of large protein 
curds is relieved by boiling the milk from two to three 
minutes over the flame, or, better, by putting in a double 
boiler and heating until the water in the outer vessel 
boils eight minutes. Although the curd is less finely 
divided by the use of the double boiler, as compared with 
boiling on the direct flame, it answers the purpose of 
most infants, and causes fewer changes in the milk. 

Addition of sodium citrate to the milk mixtures also 
prevents formation of hard protein curds. Bosworth and 
Van Slyke have shown that increasing amounts of sodium 
citrate added to the milk increases the coagulation time 
up to the point when 1.7 grains (0.1 Gm.) per ounce (30 
mils) is added, after which the milk does not coagulate 
at all. Sodium which is added replaces some of the cal- 
cium in the caseinate, and forms sodium caseinate of cal- 
cium-sodium caseinate, and when rennin is added this 
double salt is changed to calcium-sodium-paracaseinate, 
which in the presence of sufficient quantity of sodium 
does not curdle. Sodium citrate may be prescribed either 
in 5-grain tablets, adding approximately 1 grain for each 
ounce of milk in the mixture, or a prescription may be 
written in such form that each teaspoonful will contain 
sufficient sodium citrate for the day's food. 

When lime-water is added to cow's milk until it is 
neutral or faintly alkaline to phenolphthalein, a basic cal- 
cium casein is formed which is not acted upon by rennet, 
and will not form a curd, even in the presence of lime 
salts (Van Slyke). Casein is not coagulated by rennin 
when the solution is alkaline. When a sufficient amount 
of an alkali is given, the milk mixture remains neutral 



156 INFANT FEEDING. 

or alkaline in the stomach, even after the stomach has 
secreted acid, and large protein curds do not form then. 
Lime-water is commonly used in amounts equaling 5 per 
cent, of the milk in the mixture (1 ounce to 20 ounces 
of milk). 

Not infrequently we have found the adding of citrate 
of soda or lime-water to boiled milk of advantage in the 
difficult feeding cases, and in the presence of vomiting. 

Mixed Diet for Young Infants. As early as the 
second or third month, 1 or 2 teaspoonfuls of orange 
juice may be given daily. This in part at least counter- 
acts the effect of boiling. Start with 5 drops diluted with 
water, twice daily, and increase gradually. 

Fifth month, a little well cooked cereal may be added 
to one of the meals (begin with 1 teaspoonful), adding 
part of the bottle of milk to it, the meal being finished 
by the remainder of the bottle. 

At sixth month, infants readily take a broth and vege- 
table meal as a substitute for one of the milk feedings, in 
the form of a vegetable and meat soup. Begin with 1 
ounce, and follow by a second bottle containing the milk 
mixture with 1 ounce less than full feeding. Gradually 
replace an entire milk feeding. 

Ninth month, a vegetable soup or a clear broth 
(chicken, lamb, or veal), and toast or zwieback crumbs, 
with an additional portion of stewed fruits .(apples, 
prunes) or a strained vegetable (spinach, carrots, or tur- 
nips). The broth is usually given in the same quantity 
as the bottle, if given alone, or somewhat less if either 
the tablespoon of vegetable or fruit is given in addition. 



MILK DILUTIONS WITH CARBOHYDRATES. 157 

Caloric Values of Foods. 

Amount Cal. 

Apple sauce 1 ounce 30 

Bacon (slice) % ounce 30 

Bread average slice, 33 Gm 80 

Butter 1 pate (% ounce) 80 

Cereal (cooked) 1 heaping tablespoonful 

(1 ounce) 50 

Carrots (cooked) 1 ounce 13 

Crackers (soda or 

Graham) 1 ounce 100 

Cream (16 per cent.) 1 ounce 54 

Custard 1 ounce 60 

Egg 1 (1.5 ounces) 80 

Egg (white) 1 30 

Egg (yolk) 1 50 

Gelatin 1 ounce < 50 

Malt extract 1 ounce 89 

Meat 1 ounce 50 to 70 

Milk (whole) 1 pint 350 

Milk (whole) 1 ounce 21 

Potato (whole) 1 medium sized 90 

Potato (mashed) 1 heaping tablespoonful 70 

Rice (boiled) 1 tablespoonful 60 

Soup (vegetable) 1 ounce 15 

Soup (chicken) 1 ounce 8 

Toast average slice 80 

Vegetables (peas, beans, 

carrots) 1 heaping tablespoonful 30 

Vegetable (cooked spin- 
ach) 1 heaping tablespoonful 16 

These caloric values are approximate for the most part, 
but are sufficiently accurate for practical purposes. Thus 
the caloric value of a particular menu is easily figured. 

Feeding Example No. 1. Normal Infant Age Three 
Months. The infant should weigh 11 pounds (average 
birth-weight 7 pounds, plus 4 pounds, representing a 
gain of 5 ounces weekly for thirteen weeks). 



158 INFANT FEEDING. 

Estimating 1% ounces of milk per pound body weight, 
give I6y 2 ounces of milk. 

Adding three grams of cane sugar per pound or 1 
ounce for each ten pounds, is 1.1 ounces of sugar, or 2% 
level tablespoonfuls per 11 pounds 

The infant should be fed five or six times daily and 
should receive at each feeding 5 ounces of mixture (age 
in months, plus 2 ounces). To make the total daily 
quantity 25 or 30 ounces as desired it is necessary to add 
8% or 13% ounces of water to the quantity of milk as 
given above. 

For practical purposes the cow's milk may be consid- 
ered as averaging: 

Proteins 3.5 per cent. 

Fat \ 4.0 " " 

Carbohydrates ..4.0 " " 

We will now calculate the amounts of the various ele- 
ments in the mixture and the grams of each and calories 
per pound body weight in the milk mixture as given 
above for a 3 months old infant, weighing 11 pounds. 

Car bo - 

Protein Fat hydrate Salts Cal. 

Milk, 16.5 ozs = 495 mils . . 17.3 19.8 19.8 3.46 Gm. 346 

Water, 8.5 " =255 " " 

Sugar, 1.1 " = 33 Gm 33.0 .... " 132 

Total mix- ■ — — — — ■ 

ture, 25 ozs. = 750 mils .. 17.3 19.8 52.8 3.46 Gm. 478 

For each pound body weight . 1.575 1.8 4.8 0.31 " 43 

We thus find that the infant fed on the prescribed 

diet receives 25 or 30 ounces of the mixture containing: 

Protein 1.575 Gm. per pound body weight 

Fat 1.8 " " - " 

Sugar 4.8 

The mixture containing the following percentages if 
made up for 25 ounces, (It will be noted that the per- 



MILK DILUTIONS WITH CARBOHYDRATES. 159 

centages of the food elements per ounce of the mixture 
vary directly with the amount of water added and is 
therefore an unreliable basis for calculation.) and 43 
calories per pound of body weight, all of which may be 
considered as a safe minimum. 

Protein ; 2.3 per cent. 

Fat 2.64 " " 

Sugar 7.00 " " 

A fruit juice should be included in the diet (p. 156). 

It may be repeated that the needs of the Individual 
Infant are to be covered by the Diet, and food of Higher 
Caloric Value per pound body weight is needed by some 
Infants, (p. 146, 148 and 149.) 

The mixture may readily be strengthened to meet indi- 
cations for more fat and protein by the addition of milk, 
and more carbohydrate by the addition of flour and sugar. 

Form for Directions for Preparation and Feeding. 

This feeding formula may be given to the mother in 
the following form with directions for its further pre- 
paration attached. 

Name Age 

Milk 16.5 ounces 

Water 8.5 ounces 

Cane sugar 2.25 level tablespoonfuls 

(Milk Sugar : 3% level tablespoonfuls.) 

Place the above mixture in a double boiler, and starting 
with the water and the milk mixture cold, allow it to 
remain on the stove until the water in the outer vessel 
boils for 8 minutes. A small double boiler is preferable 
so as to obtain a deep column of milk, thereby holding 
the milk at a simmer. 

Feed 5 ounces at each feeding, five feedings at 4 hour 
intervals: 6 a.m., 10 a.m., 2 p.m., 10 p.m. 



160 INFANT FEEDING. 

Not infrequently while the ingredients in the diet fully 
meet the infant's needs for growth and development, the 
amount of the individual feedings are insufficient to sat- 
isfy the appetite. The infant can usually be satisfied in 
such instances by adding more water or cereal water to 
the mixture, thereby increasing the quantity of the indi- 
vidual bottle without materially altering its quality. 

It should also be remembered that some infants may 
require more milk than 1% ounces per pound body 
weight, or again, occasionally an infant cannot take a 
formula as strong as that given above, because of an 
inability to handle one or more of the cow's milk ele- 
ments, more commonly fat, protein or the excess of salts. 
In all exceptional cases the individual infant must 
necessarily have its needs fulfilled, by an increase or 
decrease in the milk components. 

Feeding Example No. 2. Normal Infant Age Eight 
Months. The infant should weigh 17.25 pounds (average 
birth- weight 7 pounds), which should be doubled in the 
first five months (14 pounds), plus a gain of 4 ounces 
a week for the remaining thirteen weeks (3.25 pounds). 

The following mixture will be prepared : 

1.5 ounces of milk per pound body weight, equals 26 
ounces. 

Water to make one quart, equals 6 ounces. 

Sugar 1.5 ounces. As stated on page 141 the amount 
of sugar to be added is usually limited to 1.5 ounces, 
further carbohydrate needs being furnished by the ad- 
dition of cereal waters or cereals. 

Starch 0.25 ounce or 8 grams (approximately % 
ounce or 0.5 grams per pound). 

This to be fed in four feedings of 8 ounces each, and 
the fifth may be replaced by a soup and vegetable meal. 



Protein 

27.3 


Fat 
31.2 


Carbo- 
hydrate 

31.2 

45.0 
8.0 


Salts 

5.46 Gm. 

it 

a 


Cal. 

546 

iso 

25 


2.0 


4.5 


8.0 


2.4 " 


144 


n- 


.... 


15.0 


" 


50 


29.3 
1.7 


35.7 
2.1 


107.2 
6.2 


7.86 " 
0.46 " 


945 

55 



MILK DILUTIONS WITH CARBOHYDRATES. 161 

A small cereal feeding (1 tablespoonful) can also be 
given with 1 or 2 of the bottles, pouring part of the 
bottle of milk over it, and finishing the meal on the 
remainder of the bottle. (See also Mixed Diet, p. 156.) 

Milk, 26.0 ozs. = 780 mils 

Water, 6.0 " =180 " 

Sugar, 1.5 " = 45 Gm. 

Starch, 0.25" = 8 " 

Vegetable 
soup, 8.0 " =240 mils 

Cereal, one heaping tablespoon- 
ful, 1.0 " = 30 Gm 

Total feeding 29.3 

For each pound body weight 

Further needs of the individual case can be supplied 
by concentrating the milk until 1 quart whole milk is 
given, the carbohydrates in the mixture being gradually 
decreased and given in another form, as gruel, custard, 
etc. 

Feeding Example No. 3. Underweight Infant, Age 
3 months. Weighing 8 pounds. To start with, prepare 
the following mixture : 

Milk 12 ounces. (1% ounces per pound present 
weight). 

Water 13 or 18 ounces. Sufficient to make 5 or 6 
feedings of 5 ounces each. 

Cane sugar 0.8 ounces (1%' level tablespoonfuls) 
(M.0 ounce or 3 grams for each pound). . 

To meet the requirements of this infant for growth and 
development, the needs of a full weight infant of the 
same age must be approximated as rapidly as the in- 
fant's tolerance for food permits. These increases can 
usually be made rapidly, if the infant is well other than 

ll 



162 INFANT FEEDING. 

for its underfeeding. The first increases being made in 
the carbohydrates in the form of further addition of 
sugar and cereal waters, until 3 grams per pound of 
sugar and 0.5 to 1.0 gram per pound of cereal flour in 
the form of cereal water are added, calculated on the 
basis of average full weight, 11 pounds, for this age. 

The milk can be increased until 1% ounces per pound 
of full weight, or 16.5 ounces for the total mixture are 
given. 

If the infant is suffering from digestive disturbances, 
it may be necessary to start with 1 ounce of milk or 
even less per pound of its present weight, that is 8 ounces 
or less in the mixture. Adding only 1 or 2 grams of 
sugar per pound. It must," however, be remembered that 
the infant will require 32 calories per pound body weight 
to sustain it. And if it is underfed for too long a 
period, it will result in inanition. 

Artificial Feeding During the First Weeks of Life. 
The rules as given for infant feeding are hardly appli- 
cable for feeding during the first one or two to three 
weeks of the infant's life. The infant's first feedings 
should consist of higher dilutions of either whole or skim 
milk, should be boiled, and sugar added in smaller per- 
centages than suggested for the older infants. Such mix- 
tures must of necessity show a lower caloric value than 
will meet the infant's needs for growth and development, 
but, as suggested, the mixture for the newborn should be 
composed of weak formulae, and increased according 
to the infant's tolerance. The following table of mixture 
will act as an outline for average cases : 



MILK DILUTIONS WITH CARBOHYDRATES. 163 

Diet for Newborn Infants During the First Four 
Weeks of Life. 

1st 48 3-4 5-6 7-8-9 10-11-12 13-14 3d 4th 
hours days days days days days week week 

Milk (whole), ozs 3 4 6 8 11 

Milk (skim), ozs 6 8 5 4 4 2 ... 

Sugar (cane), dr 112 2 2 3 4 6 

Water (boiled), ozs. .. 16 10 8 8 8 /8 8 10 

Calories in mixture .. 15 81 118 148 158 215 250 321 
Feedings : 

Amount in ozs 1 1 1.5 1.5 2 2 2.5 3 

Number daily ...... 7 7 7 7 7 7 7 7 

Intervals in hours ..33 3 3 3 3 3 3 

The above mixtures should be boiled for three minutes 
over the direct flame or in a double boiler. If the latter 
is used, the water in the outer. vessel should be boiling for 
eight minutes. Add boiled water to make up the original 
quantity. 

Method of Feeding a Baby from the Bottle. Babies 
should be fed while they are lying on their beds, the 
upper part of the body being somewhat elevated by means 
of a pillow of proper thickness. The baby should be 
turned slightly on the right side, as it has been found that 
the stomach empties itself sooner in that position. 

The bottle should always be held by the nurse or at- 
tendant, until it is empty. From fifteen to twenty minutes 
should be occupied with the meal. 

Do the above rules furnish mixtures of a quality and 
quantity proper to meet the infant's needs? If proper 
mixtures they should 

(1) Contain approximately 

Protein 1.5 to 2.0 Gm. for each pound of body weight 

Fat 1.5 " 2.0 " " " " " " 

Carbohydrates . . 4.0 " 6.0 /' " " " " " 



164 INFANT FEEDING. 

(2) Calories per pound body weight for normal 

infant : 

Under 2 months of age 30 to 45 calories 

Over 2 months of age 45 " 55 " 

(3) Percentages in the mixtures. 

It is well to know the percentages of the various ingre- 
dients in the diet, as they will assist in the proper inter- 
pretation as to the etiology of food disturbances. 

Fat. Infants, according to their age, under normal 
conditions, digest from 2 to 3.5 per cent, of fat. Some 
infants digest fat badly, consequently in some cases it is 
necessary to give skim milk. 

Proteins. In the average feeding mixture for in- 
fants under 10 months, 2 to 3 per cent, of proteins are 
well taken. 

Carbohydrates, They should,, as a rule, not exceed 
6 to 7 per cent., the average amount in human milk, in- 
cluding the sugar contained in the milk before its modi- 
fication. 

Summary. 

I. Preparation of the mixture. 

1. Calculate the baby's normal weight. 

2. Calculate the amount of cow's milk to be used in the 
preparation of the mixture, taking 1.5 ounces of cow's 
milk per pound of normal body weight at that age, which 
is a safe minimum for a healthy infant. 

3. Calculate the total daily amount of the mixture by 
multiplying the amount of each feeding (age in months 
plus 2 ounces) by the number of feedings. 

4. Add water to make the mixture up to this total 
amount. 

5. Add 3 grams of sugar, and later .05 to 1.0 gram of 
starch for each pound of body weight. 






MILK DILUTIONS WITH CARBOHYDRATES. 165 

6. Make the curd more digestible by boiling or alkalin- 
izing the mixture. 

II. Checks on the above mixture. 

1. Number of grams per pound body weight of each 
food ingredient in the mixture. 

2. Percentage of each ingredient in the mixture. 

3. Total caloric value of mixture and caloric value per 
pound body weight. 

III. Remember that — 

1. Orange juice or codliver oil additions to the diet 
should be started by the second or the third month. 

2. When more than 1 quart of milk mixture is needed 
to properly nourish the infant, the age is reached when 
a mixed diet should be instituted, 

3. These amounts are relative, and must be increased 
or decreased according to the infant's progress and in- 
dividual needs, the above rules furnishing a safe minimum 
for a healthy infant, 

4. The above amounts are usually insufficient for the 
underfed infant after it has become accustomed to the 
diet. Frequently it is necessary to approximate the re- 
quirements of a normal baby of that age. 

5. Premature and underfed infants must at first be fed 
smaller amounts. 

6. The food formula of a baby clinically healthy and 
making a satisfactory gain in % weight should not be 
changed zvithout a well-defined indication. 

Explanatory Note. For practical purposes we have used 
pounds for weight, and ounces for measuring fluids, because of 
the common use in the home of avoirdupois scales, and bottle 
and measuring glass graduated in ounces. We have also calcu- 
lated 1 oz. == 30 Gm, and 2.2 lbs. = 1 Kg. 



CHAPTER V. 

FEEDING IN LATE INFANCY AND EARLY 
CHILDHOOD. 

Feeding During the Last Quarter of the First Year. 

The following diet list will serve as an example for feed- 
ing during this period : 

Nine to twelve months diet. 

6.00 a.m. Milk mixture, 8 ounces. Milk, 6 ounces; water, 
2 ounces ; sugar, 2 level teaspoonfuls. 

8.30 a.m. Orange or prune juice, y 2 to 1 tablespoonful (0.25 
to 0.5 oz.). If preferable, this may be given 
with the 10 a.m. or 2 p.m. meal. 
10.00 a.m. Milk mixture, 8 ounces. Cereal (farina, oatmeal, 
etc.), 1 to 2 tablespoonfuls. 

2.00 p.m. Vegetable soup or a clear broth (chicken, lamb 
or veal), with an additional portion of a 
strained vegetable (spinach, carrots, potatoes, 
etc.). Vegetables can be started by the ninth 
month. The broth is usually given in the same 
quantity as the bottle, if given alone, or some- 
what less if a vegetable is given in addition. 
When starting the soup feeding, first replace 
1 ounce of the 2 p.m. bottle by 1 ounce of soup 
in another bottle; then give 7 ounces of the 
milk mixture. Gradually increase soup and 
diminish milk until an entire bottle of milk is 
replaced by soup. Gradually cut water and 
sugar out of the milk mixture until full milk 
is given by the tenth or eleventh month. 

6.00 p.m. Milk mixture, 8 ounces, and bread, zwieback 

crumbs or cereal. 
10.00 p.m. Milk mixture, 8 ounces, if needed. 

(166) 



FEEDING IN INFANCY AND CHILDHOOD. 167 

A slice of crisp bacon may be given to advantage dur- 
ing the eleventh and the twelfth months, probably best 
with the mid-morning meal. 

Four feedings a day are usually sufficient during the 
early part of the second year. In such a diet the fruit 
juices which may be given once or twice a day should 
not be considered as meals, and may be given between 
the regular feedings. Whole milk is now fed, and should 
not exceed 1 quart daily. The sugar and water are de- 
creased gradually. 

Twelve to fourteen months diet. 

6.00 a.m. Milk, 8 ounces. 

8.30 a.m. Orange juice, prune juice, or apple sauce (1 oz.) 
If preferred, this may be given with the 10 a.m. 
or 2 p.m. meal. 
10.00 a.m. Milk, 8 ounces, and cereal (farina, oatmeal, etc.) 

1 or 2 tablespoonfuls, slice of crisp bacon. 
2.00 p.m. Vegetable or cream soup and zwieback, toast, etc., 
or a clear broth (chicken, lamb or veal), with 
an additional portion of 1 tablespoonful of a 
strained vegetable (spinach, carrots, potatoes, 
etc.). The broth is usually given in the same 
quantity as the bottle, if given alone, but some- 
what less if a vegetable is given in addition. A 
little scraped beef or beef juice may occasion- 
ally be added to the vegetable. 
6.00 p.m. Milk, 8 ounces, and bread, zwieback or cereal, 

custard or pap. 
10.00 p.m. Milk, 8 ounces, if needed. 

Fourteen to eighteen months diet. 

6.00 a.m. Milk 8 to 10 ounces 

8.30 a.m. Fruit juice (orange juice, prune juice, or apple 
sauce) 1 to 2 ounces. 



168 INFANT FEEDING. 

10.00 a.m. Cereal, 2 to 3 tablespoonfuls, with 2 ounces of 
milk or cream, followed by 6 to 8 ounces 1 of 
milk. Toast, zwieback, crackers, or wafers 
may be alternated with bacon. 
2.00 p.m. (1) Vegetable or cream soup and zwieback or 
toast, or (2) a clear broth (chicken, lamb or 
veal), with an additional portion of one table- 
spoonful of a strained vegetable (spinach, car- 
rots, potatoes, etc.). The broth is usually given 
in the same quantity as the bottle, if given 
alone, but somewhat less if the vegetable is 
given in addition. Part or whole of a coddled 
egg with toast, zwieback or cracker crumbs can 
now be added to the above soup and vegetable 
meal. 

The egg may be alternated with beef juice 
or scraped beef. 
6.00 p.m. Cereal, 2 tablespoonfuls, farina, cream of wheat, 
oatmeal, arrowroot, custard or pap, with 8 
ounces of milk. Part of the milk may be given 
over the cereal, or as bread and milk, or milk 
toast. 

10.00 p.m. Milk, 8 to) 10 ounces. (Can usually be left out 
by this time.) 

Eighteen months to three years. 

7.00 a.m. Stewed fruit or orange juice; cereal; crisp bacon, 
alternate with soft boiled or poached egg; 
Bread and butter or toast; milk or weak cocoa. 
12 or 1 p.m. (1) Broth: meat or vegetable soup thickened 
with cereal. (2) Meat: lamb chops, scraped 
beef, chicken or beef juice. (3) Vegetable: 
baked or mashed potatoes; strained spinach, 
carrots, turnips or celery. (4) Dessert : gela- 
tine, custard, cornstarch or rice-pudding, or 
other simple dessert. 

6.00 p.m. Cereal and bread or cracker with milk. Baked 
apple, apple sauce or other stewed fruit. 



FEEDING IN INFANCY AND CHILDHOOD. 169 

Other Foods Permitted at Three Years. 

Meats. Broiled or boiled fish, roast or stewed poultry, 
raw or stewed oysters, broiled beefsteak, roast or broiled 
beef or mutton — all in moderate quantities. 

Eggs. Soft boiled, poached or scrambled, 1 or 2 daily. 

Cereals and Breads. Oatmeal, hominy grits, wheaten 
grits, cornmeal, barley, rice, macaroni, etc. Light and not 
too fresh wheat and Graham bread, toast, zwieback, plain 
unsweetened biscuit. 

Soups. Plain soup and broth of nearly every kind, 
preferably vegetable broth. 

Vegetables. White potatoes, boiled onions, spinach, 
carrots, peas, asparagus (except the hard part), stewed 
celery, young beets, arrowroot, tapioca, sago. 

Fruits. Nearly all, if stewed and sweetened. Of raw 
fruits, peaches are the best; pears, grapes freed from 
seeds, oranges. 

Desserts. Light puddings, as rice pudding without 
raisins, bread pudding, plain custard, pap, wine jelly, ice 
cream, junket. 

Foods to be Taken with Considerable Caution. 
Muffins, hot rolls, sweet potatoes, baked beans, turnips, 
parsnips, cabbage, egg plant, stewed tomatoes, fresh corn, 
cherries, plums, raw apples, huckleberries, gooseberries, 
currants, preserved fruits. 

Foods to be Avoided. Fried foods of any kind, 
griddle cakes, pork, sausage, highly seasoned food, pastry ; 
all heavy, doughy, or very sweet puddings ; unripe, sour, 
or wilted fruit; bananas, cucumbers, nuts, coffee, alco- 
holic beverages. 



PART IV. 

Nutritional Disturbances in Artificially 
Fed Infants. 



CHAPTER I. 
MINOR DISTURBANCES. 

1. Stationary Weight. 

Stationary weight may be relieved by the addition of : 

(1) One to 2 per cent, of starch (0.25 to 0.5 ounce, 

8 to 15 Gm.), in the form of wheat, barley, 
or rice flour, or oatmeal or barley water to 
the day's feeding, or 

(2) Addition of more sugar, if insufficient. 

(3) One or 2 per cent, of fat (cream, 1 to 4 ounces, 

30 to 120 mils), or 

(4) Skim milk. 

The ingredients to be added vary with the individual 
requirements and the preceding diet. 

2. Vomiting. 

The young infant vomits easily, and without effort. 
The weak sphincter at the cardia predisposes to regurgi- 
tation. Regurgitation of only small portion of the meal 
is designated as "spitting." This latter symptom has be- 
come less common since the introduction of the longer 
feeding interval, which allows the stomach to empty itself 
thoroughly before the next feeding. Other than too fre- 
quent feedings, too large an individual meal, and food 
(170) 



MINOR DISTURBANCES. 171 

too rapidly taken, are the most common causes of vomit- 
ing. These conditions can easily be remedied. Excessive 
handling and abdominal bands that are too tight are fre- 
quently causes of vomiting. Excessive feeding with fat, 
such as is frequently seen in formulae made from cream 
mixtures and top milk mixtures, are common causes of 
vomiting, and should lead to reduction of the fat con- 
tent of the food by replacing the contents in part by 
whole or skim milk. Excessive quantities of sugar in the 
diet may also cause vomiting. Vomiting due to the large 
tough protein curd of the raw milk can be obviated by 
boiling or alkalinizing the milk. 

3. Colic and Flatulence. 

Constipation is very frequently associated with colic 
and flatulence, disappearing with the institution of a 
proper diet. 

More commonly the habitual colic, as seen in the young 
infant, may be taken as an evidence of gastric or intes- 
tinal indigestion, and may be due to one of several causes : 
(1) too much milk at proper intervals, (2) too frequent 
feedings, and (3) mixture too rich in fat, or (4) exces- 
sive in carbohydrates. Regurgitation and vomiting are 
commonly associated, and not infrequently diarrhea re- 
sults. By careful study of the diet and observation of the 
stools the offending factor can in most instances be 
eliminated. 

Excessive flatulence can frequently be eliminated by 
reduction or change in the kind of sugar and cereal 
gruels. 

A reduction in all the elements of the food may be 
necessary temporarily in the presence of severe symptoms. 



172 INFANT FEEDING. 

Feeding of powdered casein in amounts varying from 4 
to 8 Gm., dissolved in 30 to 60 mils of water, two or three 
times daily, will relieve colic in many infants, in all 
probability due to lessening of intestinal peristalsis. 

Not infrequently the crying due to underfeeding may 
be interpreted as colic. Reduction of the diet of these 
infants is a source of danger. If the stools are good, and 
there is no vomiting, and the baby is gaining in weight, 
one should be convinced that it is not the cry of habit 
before making changes in the diet. 

The constant solicitude of nurses because the baby 
has "gas on the stomach" is unwarranted. All bottle-fed 
babies have gas in the stomach. They swallow it with 
their meals in the form of air. If the baby is gently 
raised in the sitting posture the gas will usually "come 
up." This may be done in the middle of a feeding if the 
stomach seems unusually distended. Occasionally severe 
attacks of colic may be relieved by a saline enema. 

4. Constipation. 

In breast-fed babies, and not infrequently in infants fed 
on boiled milk, we frequently find a sluggish rectum, 
which is evacuated to better advantage by the use of 
simple mechanical means than by the use of physics. A 
lubricated catheter, a simple suppository, made from 
glycerin or soap, or 1 to 2 ounces of a saline enema or 
sweet oil injection can be recommended. If properly 
used, they are not harmful, nor do they create bad habits 
which are often ascribed to them. A regular hour for 
their use, with proper training, creates regular habits, and 
in most instances the condition improves to such an ex- 
tent that they can be discontinued. Most infants can be 
trained to regular evacuations by the fourth or fifth 



MINOR DISTURBANCES. 173 

month. The infant should be well supported on the 
mother's lap, over a chamber, which she may hold be- 
tween her knees. This is done to best advantage after a 
feeding, and a suppository may be used until the infant 
realizes that the operation is undertaken for a purpose, 

In the presence of fat-soap stool it may be necessary to 
reduce the whole milk, substituting skim milk tempor- 
arily, and increasing the sugar. 

In the presence of constipation, where the maltose-dex- 
trin compounds have been used, a change to milk-sugar or 
cane-sugar, or one of the dextrin-maltose compounds con- 
taining a high percentage of maltose and potassium car- 
bonate, is often beneficial. 

Occasionally, the addition of cereal water to the diet 
is of benefit. The reverse, however, may be true. 

When the infant is old enough, constipation is best re- 
lieved by the addition of vegetable or fruit purees. 

When the above fail, the addition of 1 or 2 teaspoon- 
fuls of milk of magnesia (magma magnesise, N. F.) to 
the day's feeding answers well for temporary use, or 1 or 
2 tablespoonfuls of dri or liquid malt soup extract added 
to the day's feeding acts equally well. 

In infants where constipation is distressing, and other 
dietetic changes fail, a week or two on Keller's malt soup 
usually works wonders. 

Underfed infants frequently suffer from constipation. 
Such stools (hunger stools) are small, dark in color, and 
contain much mucus, and are associated with stationary 
weight. Increasing the diet relieves the constipation. 

5. Abnormal Stools. 

(1) Curds, Curds are seen as undigested masses, 
and may be formed from fat or protein, or a combina- 
tion of the two. 



174 INFANT FEEDING. 

Fat curds are far more common than protein curds, 
and are usually seen as small, soft, whitish or yellow 
masses, either sprinkled throughout the stools or not in- 
frequently making up a large part of the stool. They are 
usually intermixed with mucus, which is present in ex- 
cess. The chemical composition can easily be demon- 
strated by the usual tests for fat. Breast-fed infants very 
commonly show curds of this type, and usually they have 
very little pathological significance in these infants. 

Protein curds are far less frequent, and present quite 
a different appearance. They are also seen only in the 
presence of feeding with raw milk. They appear as 
smooth, hard masses, of a yellowish-brown color, with 
white center when broken, and are usually larger than 
the fat curds. They are also smaller in number, and may 
be found mixed in feces which otherwise appears normal. 
The laboratory test (ether), which causes the fat curds 
to go into solution, results in hardening and toughening 
of the protein curds. This is an easy method of differen- 
tiation. Such stools have usually an offensive odor. 

Treatment. The fat curds, if numerous, call for a 
considerable reduction in the fat percentage. The protein 
curds, if numerous and persistent, should lead one to re- 
duce the protein, at least temporarily, or also to boil- 
ing or citrating the milk, which causes their disappear- 
ance. In a dyspeptic infant with hard curds in the stools, 
removing the sugar from the raw milk mixture, thereby 
lessening the frequency of stools and slowing peristalsis, 
may cause the hard curds to disappear — that is, a sugar 
diarrhea that caused a non-digestion of the casein has 
been remedied. 

(2) Loose, green stools with a sour odor may be due to 
a high percentage of sugar, more commonly milk-sugar, 



MINOR DISTURBANCES. 175 

or, again, they may be due to an excess of fat. Such 
stools are usually frequent, and, if the dietetic error is 
not corrected, may lead to nutritional disturbances. 
Stools of similar appearance, which are not infrequently 
seen in breast-fed infants, have far less significance, and 
should not lead to weaning if the child is making at least 
a fair progress. In the artificially fed, the treatment con- 
sists in the careful study of the diet, with removal of the 
cause, when found. 

(3) Fat-soap Stools. These are light-colored, large, 
dry stools, which do not adhere to the napkin, and are 
seen in feeding in which cream or cow's milk is in excess. 
They are described more fully under Disturbed Metabolic 
Balance. 

(4) Starvation stools have already been described. 

(5) Blood in Stools. This may be associated with 
many different conditions, and the character of the stool 
differs with the source of the hemorrhage into the intes- 
tinal tract, and may vary from a tarry stool to one con- 
taining bright blood. 

6. Milk Idiosyncrasy. 

A few infants show a true idiosyncrasy to cow's milk, 
which is overcome only with great difficulty, even when 
the milk is carefully modified. The true cause of this 
condition is still in dispute. However, it may be said 
that some of these cases are undoubtedly due to anaphy- 
laxis. On the other hand, some of them are undoubtedly 
not explained on this basis. Infants suffering from such 
idiosyncrasy will usually refuse the milk, and when it is 
forced upon them it results in vomiting, diarrhea, and 
frequently an urticario-erythematous rash. Cow's milk 
feeding in these cases is often associated with a low- 



176 INFANT FEEDING. 

grade fever. The symptoms speedily subside upon the 
administration of castor oil and the withdrawal of milk. 
This class of cases offers great difficulty in feeding during 
the first year of life, as carbohydrates must necessarily 
form a considerable portion of their diet. Broths, cooked 
cereals, and vegetable purees should be gradually added 
to the diet as soon as they can be digested. 



CHAPTER II. 

GENERAL CONSIDERATION OF NUTRITIONAL 
DISTURBANCES. 

Our ideas on this subject have undergone considerable 
change during the past few years. Older authors viewed 
the nutritional disturbances as conditions limited to the 
stomach and bowel, and likened them to similar condi- 
tions in the adult, with the exception that more serious 
results were to be expected in the infant because of the 
slight physiological resistance. The infant's body is more 
favorable to a severer course. 

For many years the classification of Widerhof er, of the 
Vienna school, first published in 1880, and based on an 
anatomico-pathological basis was the one in general use. 
These he grouped as follows : 

1. Functional disturbances, as acute and chronic dys- 
pepsias. 

2. Enterocatarrhs, with more or less marked histo- 
logical changes and clinical findings. 

3. Follicular enteritis, with deep-seated inflammatory 
and ulcerative changes, especially in the large intestine. 

4. Cholera infantum (this latter, a severe type of en- 
terocatarrh, was classed as a distinct clinical entity). 

Clinical observation soon convinces one that the cases 
do not follow the distinct types in the above classification, 
mixed and progressive types being the rule. In many in- 
stances far-reaching after-effects remain, and, again, in 
others of the severest types few if any anatomical lesions 
were demonstrable at autopsy. Especially in young in- 
fants we find marked and often general disturbances fol- 

12 (177) 



178 INFANT FEEDING. 

lowing in the wake of what seemingly were localized gas- 
trointestinal lesions, with the result that the systemic and 
not the intestinal symptoms were of more serious import. 
Again, we know that many findings formerly attributed to 
invasion of bacteria or their toxins can now be at- 
tributed directly to improper metabolism of the food 
ingested. 

To avoid confusion in our discussion of this vast field 
of nutritional disturbances, we will first consider the food 
injuries, and speak only of the infections incidentally as 
they affect the former, and at a later period discuss the 
infections more directly. 

Food Injuries. The nomenclature covering this sub- 
ject has also changed, and we now adopt the term 
"Nutritional Disturbances" in place of "Gastro-intestinal 
Diseases," the former covering the functional and ana- 
tomical disturbances, as well as the bacterial and food 
traumas. It is, however, necessary in order to justify 
the newer nomenclature to look upon nutritional disturb- 
ances not as localized in the gastro-intestinal canal, but 
as general affections involving the whole organism in one 
of the most vital of its functions. The gastro-intestinal 
symptoms form only a part of the clinical picture ; there- 
fore, in its fullest conception the mental state, changes 
in the temperature, pulse, respiration, etc., may become 
as important in their interpretation as the diarrhea. Two 
schools of pediatrics have given us the nucleus for our 
present views on nutritional disturbances and their classi- 
fication — those of Czerny and Finkelstein. Czerny's 
work antedated that of Finkelstein by several years, and 
he based his classification on what he considered injuries 
due to overfeeding with individual food elements. These 
he called "food injuries," and described them as due to 



NUTRITIONAL DISTURBANCES 179 

fat, starch, sugar, protein, and salts, individually or in 
combination, either when given in excess, or when given 
to an infant with lowered tolerance for these food 
elements. 

Finkelstein viewed the nutritional disorders from a 
broader standpoint. He considered them "as the gradual 
development of an increasing intolerance for food" — 
step by step, from the mildest disturbances, in which the 
only striking symptom is failure to gain in weight, 
through the severer dyspepsia, up to the final stage of 
intoxication, when the infant is in a state of "metabolic 
bankruptcy!' In his classification we see one increasing 
process, the important factor of which is found in the 
fact that the infant can tolerate less and less food, until 
finally any food ' in any amount acts harmfully. The 
stages of the various disorders under the Finkelstein 
classification must therefore necessarily merge gradually 
into one another, and lack in definiteness, and at times 
present a picture so complicated that an exact diagnosis 
as to the stage be temporarily impossible. 

Etiology in General. Before entering upon a gen- 
eral discussion, it may be wise to review some of the 
theories promulgated for the advantages of human over 
cow's milk in infant feeding. Biedert believed that the 
decomposition products of protein digestion were the im- 
portant factors. This idea has not been substantiated 
clinically. Hamburger advanced the idea that the albu- 
mins foreign to the human body contained in cow's milk 
were important factors. This also has not been proven. 
Czerny believes that the fat, and, again, the sugar, are 
the important factors. L. F. Meyer believes that the 
whey content, and more especially the high salt content 
of whey (0.75 per cent, as compared with 0.2 per cent. 



180 INFANT FEEDING. 

in human milk), predisposed to intestinal injury, follow- 
ing which trauma fats and sugars play an important part. 
Marfan, Escherich, Pfaundler, and others believed that 
specific protective bodies of unknown nature were con- 
tained in raw human milk, which are of vast importance 
as immunizing bodies. 

Of greatest importance as etiological factors, as viewed 
by Finkelstein, are the fermentation products of the fats 
and carbohydrates, which result in the formation of the 
lower fatty acids (lactic acid, butyric acid, etc.). Protein 
decomposition is evidenced only by its causing increased 
intestinal secretion, a very bad odor of the stool, and a 
tendency to constipation, except in the presence of large, 
raw curds, with their tendency to mechanical irritation. 
The acids formed by fat and carbohydrate metabolism 
when in excess result in increased peristalsis, increased 
secretion of mucus, etc. They may also interfere directly 
with intestinal digestion, or cause irritation of the in- 
testinal wall itself. In mild cases this may result only in 
impaired growth and progress, but in the severer types 
of nutritional disturbances there is breaking of the nor- 
mal relation between intestinal digestion and the paren- 
teral cellular metabolism, whereby the whole body func- 
tion may be impaired, due to toxic products escaping 
through the intestinal wall into the general circulation, or, 
again, products necessary to normal growth may be lost 
into the intestinal tract. 

We know that bacteria and their toxic products, as 
encountered in the food administered, are less often 
the offending factor than formerly supposed, and that 
improper food either qualitatively or quantitatively are 
of equal or greater importance in the causation of nutri- 
tional disturbances. Food injuries can therefore be due 



NUTRITIONAL DISTURBANCES 181 

to : ( 1 ) underfeeding by a generally restricted or an im- 
properly balanced diet, (2) overfeeding with a food of 
proper or improper proportions, (3) lessened tolerance 
for food. 

1. Nutritional Disturbances Following Underfeeding. 
We recognize two types: (1) qualitative and (2) quanti- 
tative. Sooner or later the results are similar. The 
former diets, qualitatively wrong, are frequently seen 
where theoretically the caloric requirements are met, but 
one or more of the necessary food elements are in excess 
and the mixture short in the required amounts of others. 
An example of this is seen in feeding of carbohydrate- 
rich foods as condensed milk, malted milk, etc. When 
the minimum requirements for growth and development, 
at least for both organic and inorganic salts are met in 
such a diet, the organism may be able to overcome the 
excess of one ingredient, but if this is not true, sooner or 
later some grave complications will result. When we 
feed less than a sustaining diet of 32 calories per pound 
body weight, or 70 calories per kilogram, we soon have 
the results of a quantitative inanition, with all of its un- 
desirable results. 

2. Nutritional Disturbances Due to Overfeeding. This 
is probably the most important of all etiological factors, 
and may be due to a diet of correct proportions, but quan- 
titatively too great for the individual case, or a diet with 
an excessive amount of one or more constituent ingred- 
ients. 

To judge such errors in diet, each individual infant 
must be studied as a distinct entity. 

3. Nutritional Disturbances Due to a Primary Lessen- 
ing of Tolerance to Food. Many factors can cause such 
a state of affairs: 



182 INFANT FEEDING. 

(a) Intercurrent illness, with impairment of the 
digestive function. Bacterial infections are 
probably the most common, and may be 
either general or localized infections. 

(&) Heat of summer, with its depressing influence 
on the organism. 

(c) Spoiled milk, due either to bacteria contained or 

their products. 

(d) Improper hygienic conditions, with their result- 

ing depression. 

General Symptomatology. The varied symptoma- 
tology of the nutritional disturbances can only be realized 
when we consider the numerous factors involved in the 
process of nutrition. We must, therefore, consider the 
digestion of foods in, and their absorption from, the in- 
testinal tract, the replacing and upbuilding of the body 
tissues, heat production and regulation, and the con- 
trol of the functions of all organs and tissues. That 
nutrition influences all of these functions is evidenced by 
the disappearance of the so-called alimentary fever, by 
the withdrawal of food. This is also true of certain 
forms of albuminuria. We also find cerebral and spinal 
symptoms as well as cardiac and respiratory changes, 
which readily disappear with a corrected diet. 

By the development of the foregoing symptoms in their 
various phases, and under varied conditions, we can ex- 
pect the most divergent clinical pictures. The individual 
type varies directly with the general condition of the 
infant, as well as with the predominating dietetic ele- 
ments. All infants suffering from nutritional disturb- 
ances have a lessened food tolerance. This has a far- 
reaching effect, even to the involvement of the most re- 



NUTRITIONAL DISTURBANCES 183 

mote tissues and cells, which, again, is evidenced by a 
general weakening of all body functions. The end re- 
sult is a paradoxical reaction to food intake, which is evi- 
denced by loss of weight, irregularities in the tempera- 
ture curve, etc., on food administration beyond the point 
of tolerance. These evidences of disturbed metabolism 
vary directly with the variety and quantity of food intake, 
and with the degree of metabolic disturbance which has 
preceded. A good example of this reaction is seen in 
the following series of cases : Three infants each are fed 
30 Gm. of sugar daily, added to their ordinary diet. The 
first baby, a well one, gains in weight somewhat more 
rapidly than previously; the second develops diarrheal 
stools, a slight irregularity in the temperature curve, and 
its weight remains stationary; while the third infant, 
which was more deeply involved, develops a temperature 
of 101° and over, very frequent stools, and loses 100 Gm. 
in weight in twenty-four hours. Lowered resistance is 
not alone evidenced in the reaction to food, but also are 
lessened immunity to infection, and marked depression by 
hot weather. All of these may be followed by severe 
systemic infections, and markedly retarded convalescence. 

The normal healthy infant with a well-balanced metab- 
olism reacts to food as follows : 

1. An elastic, pink skin, a well-developed panniculus 
adiposus, well colored mucous membrane. Its tissues 
should feel firm. 

2. One should expect certain muscle and bone develop- 
ment according to the age of the infant. 

3. A uniform rectal temperature (98° to 99° F.), 
almost a monotheria. Any considerable deviation is 
abnormal. 



184 INFANT FEEDING. 

4. It should show a regular, steady gain in weight. 

5. The bowel movements should be regular, and should 
vary with the food ingested. 

6. Its disposition should be happy, and its nervous 
functions normal. It should sleep well, and be satisfied 
with feedings at three- to four- hour intervals. 

7. It should show a wide tolerance for food, both as 
to the diet as a whole, and to the individual food element. 

8. Renal, circulatory, and respiratory functions should 
be normal. 

Bearing in mind the attributes of the healthy infant, 
we are now in a position to review the factors leading to 
and influencing our present conceptions of the nutritional 
disturbances, based on an ascending series of pathological 
stages in those infants whose tolerance for food has been 
overstepped either because of overfeeding or because of 
diminished or abnormal tolerance on the part of the 
baby itself. 

Classification of Nutritional Disturbances. The older 
classification into acute and chronic dyspepsia, entero- 
catarrh, ileo-colitis, and cholera infantum must be dis- 
carded in the light of our new knowledge, and the whole 
reclassified, with the view in mind that the gastric and 
intestinal symptoms are only local evidences of a general 
systemic involvement, with the clinical picture varying as 
to the predominating food elements, the preceding gen- 
eral condition of the infant, and the knowledge that 
changes are rapidly seen from one type to another 
through the influence of various exogenic factors. 

For our purposes we will combine the essentials of the 
Czerny and Finkelstein classifications into a working 
basis. 



NUTRITIONAL DISTURBANCES 185 

Etiological Classification. 

Group I. Nutritional disturbance (food injuries) due 
to overfeeding (overstepping the infant's food tolerance) 
in the absence of any predisposing cause. 

Group II. Nutritional disturbance due to underfeed- 
ing. (Insufficient food. Inanition). 

(a) Quantitative inanition. 

(Pyloric stenosis, pylorospasm, etc.) 

(b) Qualitative inanition. 

(1) Excessive Starch (flour) feeding. Not due 

to excess of starch alone, but to the lack 
of other ingredients in the diet. 

(2) Scorbutus. 

(3) Rachitis. 

Group III. Secondary nutritional disturbances. In 
these conditions the food tolerance has been lowered by 
factors other than metabolic. Food which under normal 
conditions is proper becomes excessive and the lowered 
food tolerance is thus being overstepped. This may 
result in the development of any of the syndromes to be 
enumerated under Clinical Classification. 

(a) Heat resulting in systemic depression and often 

associated with spoiled foods (milk, etc.). 

(b) Infections from within the intestinal tract 

(enteral). 

(1) Non-specific intestinal infections (ileocolitis, 

etc.) 

(2) Specific intestinal infections (typhoid, para- 

typhoid, dysentery, etc.). 

(c) Systemic infections (parenteral). 
Otitis, pyelitis, pneumonia, etc. 

Group IV. Nutritional disturbances due to congenital 
debility, anomalies or idiosyncrasies with resulting ab- 



186 INFANT FEEDING. 

normal metabolism. These disturbances are produced by- 
food that would be qualitative and quantitatively proper 
for a healthy infant. 

(a) Exudative diathesis (eczema, etc.). 

(fc) Psychoneuropathic diathesis. 

(1) Neuropathic (strict sense). 

(2) Spasmophilia (tetany, convulsions, etc.). , 

(3) Habitual vomiting. 

(4) Pylorospasm. 

Clinical Classification. 

In the clinical pictures that may develop on the basis of 
the above mentioned etiology, several more or less dis- 
tinct types or syndromes may be differentiated. These 
may be dependent primarily or exclusively upon the 
dietetic errors as in Groups I and II, or they may be 
influenced by secondary etiological factors as enumerated 
in Groups III and IV. The reaction to food administra- 
tion is the basis of this clinical classification, and the 
degree of reaction depend upon the extent of disturbance 
of infant's metabolism. 

The following constitute clinical syndromes or types 
of nutritional disturbances : 

Type 1. Disturbed metabolic balance. 

Type 2. Dyspepsia. 

Type 3. Decomposition. 

Type 4. Intoxication. 

Type 5. Inanition (primary). 

The type 1 and 2 are light forms without destructive 
lesions. Types 3 and 4 are severe forms with destructive 
lesions and general disturbance of the whole organism. 
While the Types 1, 2, 3, and 4 are wholly or partially due 
to absolute or relative overfeeding, the Type 5 represents 



NUTRITIONAL DISTURBANCES 



187 



that form of inanition in which the food either quantita- 
tively or qualitatively insufficient is the only etiological 
factor. 

It must also be remembered that one form leads 
rapidly into another, if the errors in the diet are not 
remedied, or when secondary infections complicate the 
picture. 

The following scheme may be used for classifying the 
main clinical types due to overfeeding : 



Dis. Met. 
Balance 



Dyspepsia 



Decomposition Intoxication 



Lessened fat Lessened fat and Tolerance lowered Follows other 

tolerance. Food carbohydrate to all food forms, especially 

of sufficient tolerance. Rel. elements. when a diet rich 

caloric value. excess of sugar in whey and 

in the food. sugar is not 

corrected. 



Stationary Stationary weight Rapid loss of 

weight. or moderate weight, 

loss. 



Slight variations Moderate fever, 
in temperature. 

Constipation with Diarrhea, green, 

fat-soap stools. mucus, curds, 
acid. 

Absence of acute Acute 

symptoms, gastro-intestinal 

general loss of symptoms, 
turgor. 



Subnormal 
temperature. 

Often history of 
diarrhea. May 
be constipated. 

Weak, slow, 
small pulse. 
Hunger. 
Vomiting. 



Sensorium not 
involved. 



Sensorium not 
involved. 



Favorable 
reaction to 
reduction of fat 
and increase of 
carbohydrates in 
the diet. 



Rapid repair on 
withdrawal of 
improper food. 



Sensorium not 
involved. 



Starvation 
dangerous, also 
great danger in 
overfeeding. 



Rapid loss of 
weight. 



High fever. 



Diarrhea, watery, 
blood, etc. 



Rapid, weak, 
small pulse. 
Rapid, pauseless 
respiration. ' 
Hunger. 
Vomiting. 
Collapse. 
Glycosuria. 
Albuminuria. 
Anuria. 
Leucocytosis. 

Sensorium 
markedly 
involved. 
Nervous 
symptoms 
may outweigh 
intestinal 
symptoms. 

Improvement on 
withdrawal of 
food. 



CHAPTER III. 



DISTURBED METABOLIC BALANCE. 



Synonyms. Weight disturbance, disturbed balance, 
fat constipation, malnutrition, atrophy of moderate de- 
gree, Bilanz-Stoerung (Finkelstein), Milchnaehrschaden 
(Czerny-Keller). 

This represents the mildest stage of nutritional dis- 
turbances, and results from administration of food be- 
yond the infant's limits of tolerance, resulting in retarda- 
tion of development, both qualitatively and quantitatively, 
however, without marked general symptoms of disease. 
This condition is clinically characterized by pallor, rest- 
lessness, disturbed sleep, constipation, usually associated 
with fat-soap stools, and stationary weight. Fortunately, 
this clinical picture is less frequently seen than formerly, 
when cream and top milk mixtures were more extensively 
used. 

Etiology. It is seen under a variety of conditions : 

1. Most cases are caused by a relatively high fat con- 
tent of the food, i.e., a relative overfeeding with whole 
milk, in the presence of moderate amounts of carbohy- 
drates ; therefore we have improper proportions of carbo- 
hydrate and fat. In the presence of excessive amounts 
of carbohydrates we are more likely to see a dyspepsia. 
Proteins also play an important role in the causation of 
the clinical picture of this disease, in that in the presence 
of a relative overfeeding with proteins an alkaline intes- 
tinal reaction necessary to the production of fat-soap 
stools is brought about. The symptoms usually follow a 
(188) 



DISTURBED METABOLIC BALANCE. 189 

period of good progress, which ceases more or less 
abruptly. 

2. Cases in which the milk mixture is theoretically 
quantitatively correct, but in which the infant suffers 
from a congenital idiosyncrasy to milk. Many of this 
class of cases are associated with exudative diathesis. 

3. Following lowered food tolerance due to intercur- 
rent infections, either parenteral or enteral. 

Artificially fed infants are almost exclusively affected, 
probably because of the high carbohydrate and low pro- 
tein content in the breast-fed infant's food. This con- 
dition was first described by Czerny under the name of 
Milchnaehrschaden, having been first noticed in those 
infants who received large quantities of fat in the food. 
This may be due to an absolute excess of fat, as seen in 
the first group, or a relative excess of fat, as seen in the 
second group of infants having an idiosyncrasy toward 
milk. Fortunately, in these infants the tolerance for car- 
bohydrates has in most cases not been reduced, and there- 
fore the fat in the food can to a great degree be replaced 
by sugar and cereals. 

Pathogenesis. As fat-soap stools are so frequently 
regarded as the basic symptom in the diagnosis of dis- 
turbed metabolic balance, we will first emphasize their 
significance. The fat-soap stool must be viewed as an 
effect, and not as the cause, of this intestinal disturbance. 

The condition is not a fat indigestion, but a disturbance 
in salt metabolism, based on a relative overfeeding of fat 
in the presence of a relative carbohydrate underfeeding, 
and enhanced by a relative excess of protein. 

There is an increased excretion of the alkalies by in- 
creased combining of alkalies with fatty acids, and 
through loss of alkalies by increased intestinal secretion. 



190 INFANT FEEDING. 

The alkalies most involved in the formation of the fat- 
soap stools which are so commonly seen in this condition 
are calcium and magnesium. There is, however, also a 
decreased sodium and potassium retention, as evidenced 
more especially by increased excretion in the urine. This 
loss of calcium and magnesium through the stools, and 
inability to retain sodium and potassium, and thereby 
secondarily a loss in water retention, soon leads to weight 
loss. The fat-soap stools as stated, contain an excess of 
calcium and magnesium soaps, and less fatty acids and 
neutral fats than seen in the normal stools. 

To obtain such a stool, there must be a strong alkaline 
reaction in the large intestine, and the food elements of 
the diet are important factors in the production of this 
reaction. 

Fats. An excess of fats in the food leads to an ex- 
cess of fatty acids in the intestine, with a tendency to 
the formation of an acid reaction of the intestinal con- 
tent. To combine with these, alkalies are withdrawn 
from the body, if insufficient in the intestinal tract. 

Proteins cause secretion of a large quantity of intes- 
tinal juice which is alkaline. This in time tends to pro- 
duce an alkaline intestinal reaction, if not counteracted 
by excessive fermentation, the former being favorable to 
the formation of fat-soap stools. In all probability the 
great calcium content^ of cow's milk (4 to 1), as com- 
pared with breast milk, also offers another factor in the 
tendency to formation of calcium soaps. 

Carbohydrates. In the presence of sufficient ferment- 
able carbohydrates (disaccharides) in the diet, the intes- 
tinal reaction becomes acid, the products of fermentation 
counteracting the tendency to alkaline reaction, and thus 
preventing the formation of fat-soap stools. 



DISTURBED METABOLIC BALANCE. 191 

The withdrawal of excessive amounts of alkalies from 
the system disturbs the acid-alkaline equilibrium, creating 
a relative excess of acids, i.e., the formation of an acid- 
osis. This is evidenced by the increase of the ammonia 
coefficient in the urine, i.e., the relation between the am- 
monia and the total nitrogen products. 

In disturbed metabolic balance we find a striking ex- 
ample of a paradoxical reaction, namely, increasing the 
food (milk or fat) makes the condition worse, and causes 
weight loss, diminishing the food, a return to normal, 
and if properly changed, even though lessened, a gain in 
weight. 

The clinical picture is due to: 

1. Excessive withdrawal of salts from the body tissues, 
due to fat and protein overfeeding. 

2. A relative insufficiency of carbohydrates. 

The stools are dependent upon overfeeding with milk, 
with insufficiency of carbohydrates. To be considered 
pathological, they must be accompanied by systemic 
manifestations. 

The same stool may be seen under normal conditions 
in high protein and low fat feeding, more especially in 
the feeding with boiled milk, as a strong alkaline intes- 
tinal reaction is the paramount condition upon which 
their formation is dependent. 

Symptoms. There is a retarding of development 
qualitatively and quantitatively, the infants frequently be- 
ing undersized, without showing marked general symp- 
toms of disease. 

1. Weight. Notwithstanding proper or even excessive 
caloric intake, there may be no gain in weight, or an irreg- 
ular increase, however, under the normal. (Stationary 
weight or insufficient gain in the infant corresponds to a 



192 INFANT FEEDING. 

loss in weight in the adult. Stationary weight in an in- 
fant alone leads to the picture of malnutrition and 
marasmus.) 

2. Temperature. Usually we find daily oscillations 
from 1° to 2°, with a tendency toward subnormal. 

3. The child is restless. 

4. Sleep is disturbed. 

5. The skin is pale, with loss of elasticity and turgor. 
Intertrigo and eczema are frequently seen. 

6. Muscles are soft and flabby. 

7. Regurgitation and vomiting are frequent. 

8. Abdomen tympanitic. 

9. Stools. In excessive milk feeding the common type 
is the fat-soap stool, which is foul-smelling, dry, light in 
color (gray to white), friable, and does not stick to the 
napkin. The pale color is due to the reduction of bili- 
rubin to urobilinogen. The odor, in part at least, is due 
to the decomposition of protein. In the presence of ex- 
cessive carbohydrates this stool may be lacking, due to 
the presence of a slight dyspepsia. 

10. Immunity is lessened with resulting furunculosis 
and susceptibility to respiratory, gastro-intestinal, and 
genito-urinary infections. 

11. Urine is usually ammoniacal, and contains an ex- 
cess of sodium and potassium salts. 

Diagnosis must be based on the clinical picture and 
feeding history, as follows: sufficient caloric intake (100 
calories per kilogram), with relative excess of fat and 
protein, and insufficiency of carbohydrates, absence of 
diarrhea, stationary weight, and lack of proper develop- 
ment, all in the absence of any other causative factor. 



DISTURBED METABOLIC BALANCE. 



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194 INFANT FEEDING. 

Underfeeding and all past illnesses which might retard 
development must be excluded. 

Prognosis is very favorable in uncomplicated cases, 
with a properly instituted diet. In the average case two 
to three weeks is required to overcome the constipation, 
and to obtain a gain in weight. Occasionally a severe 
type is seen which is difficult to overcome, most com- 
mon in infants with an idiosyncrasy to cow's milk. 

Complications. Because of the lowered immunity, 
infections are common, especially of the nasopharynx, 
lungs, middle ear and skin and gastro-intestinal and 
genito-urinary tract. Exudative diathesis is not an un- 
common associated condition. 

Sequellae. Disturbed metabolic balance is often the 
forerunner of the more serious nutritional disorders, 
such as dyspepsia, decomposition, and intoxication. 
Chronic constipation frequently results, due to the atony 
of the intestinal wall and abdominal muscles. Rickets 
frequently develops in these infants. 

Treatment. To institute a proper treatment, we 
must remember that the clinical picture is not dependent 
on gastro-intestinal findings only, but also on an abnor- 
mal intermediary metabolism (therefore the designation 
Disturbed Metabolic Balance), and that fat overfeeding 
primarily, and a carbohydrate insufficiency secondarily, 
are causative factors, and that protein overfeeding may 
be an important element. 

1. Diet with Human Milk. This is by all means the 
best treatment, especially in young infants. Weight in- 
crease may be slow at first, probably due to low salt and 
protein content of human milk. A loss of more than 6 
to 10 ounces over a period of three or four days is fre- 



DISTURBED METABOLIC BALANCE. 195 

quently seen. More than this should lead one to suspect 
an error in diagnosis. This loss may be due, as stated, 
to stopping of a food rich in proteins and salts, and sub- 
stituting one low in the same. This stage is passed in 
about four days, when the system adapts itself to the new 
food ingredients. Temperature and pulse do not change, 
and the stools assume a breast-milk-stool character. If 
the stage of reparation is slow, and the child does not 
gain in weight, the substitution of one meal rich in pro- 
tein and salts daily will frequently help (buttermilk or 
skim milk). Mother's milk also helps to increase the 
immunity. 

2. Diet with Artificial Foods. In pathogenesis of this 
condition the milk fat plays the most important role, and 
this is best counteracted by replacing it with well-toler- 
ated carbohydrates. Protein tolerance is usually little im- 
paired, so that high percentage may be retained in the 
diet in the presence of increased carbohydrates. 

(1) In simple cases reduce the quantity of milk and 

add carbohydrates in the form of sugar and 
starches. 

(2) In severer cases 

(a) Malt soup (Keller's) (p. 288) is exceedingly 
valuable. Malt soup is indicated in the 
presence of fat-soap stools which soon be- 
come pasty and of mahogany-brown color; 
the best results with malt soup are obtained 
in infants from three to six months of age. 
After six months more milk than given in 
the original formula must be added to in- 
crease the protein content of the diet. 

(&) Buttermilk or skim milk mixtures (contain- 
ing two carbohydrates, i.e., sugar and 



196 INFANT FEEDING. 

flour). The action of both is the same. 
Occasionally it is necessary in young in- 
fants to reduce the sugar recommended in 
the original formula (see Buttermilk Mix- 
ture, p. 286). 
(c) Brady's buttermilk mixture No. 1 (p. 286). 
Change of the diet is followed by better sleep, im- 
proved turgor, skin becomes less pale, less variation in 
temperature. Stools change from soap stools to (1) yel- 
low-brown, alkaline and fair consistency, when butter- 
milk mixtures are fed, (2) acid, softer, mahogany- 
brown color when malt soup is fed. 

These results of treatment are due to the fact that the 
tolerance for carbohydrates is high, and protein toler- 
ance is little impaired. Each case should be watched to 
see if an excess of carbohydrates is not being given in 
the new diet, which is indicated by (a) restlessness, (&) 
stopping of weight increase after an early rise, (c) ali- 
mentary fever (irregular), (d) too frequent stools. If 
the cow's milk mixtures are not well tolerated, human 
milk is indicated. 

The above mixtures should be gradually replaced by 
ordinary milk mixtures after two to eight weeks. 

In infants over six months of age one of the most con- 
stant and brilliant therapeutic results follows the use 
of a limited amount of milk (boiled or citrated) and the 
free administration of toast, zwieback, rusk, and cooked 
cereals given in increasing quantities up to amounts that 
will bring on a steady gain of 6 to 8 ounces a week. To 
this diet broth or vegetable soup and orange juice should 
be added soon. In other words, if a baby of six or seven 
months does not gain on ordinary milk mixtures, it should 
be fed like a normal baby of nine or ten months, with 



DISTURBED METABOLIC BALANCE. 197 

the single exception that the milk should be kept rather 
low, or at least given cautiously, and preferably boiled 
or citrated, or both. In many cases this can be done 
even in the fifth month. 



CHAPTER IV. 
THE STAGE OF DYSPEPSIA. 

Synonyms. Stadium dyspepticum, sugar indigestion, 
fat indigestion, Zuckernaehrschaden. 

Etiology. Dyspepsia may develop either primarily 
in a healthy child or as a sequel of disturbed metabolic 
balance, when the insufficiency of the intestine has be- 
come such as to make it impossible to avoid development 
of pathological fermentation. This may be due either 
to absolute or relative overfeeding, or because of pri- 
mary influence, which tends to decrease the food toler- 
ance. The products of fermentation cause increased 
peristalsis, which leads to the chief symptom of dyspep- 
sia, diarrhea. 

The most important factors may be enumerated as 
follows : 

1. Errors in diet with milk of good quality: (a) over- 
feeding with diet of normal proportions (too frequent 
and too much) ; (&) feeding with a diet of improper pro- 
portions (excess of sugar, or fat absolute or relative, 
etc.) ; (c) excess of raw milk, with resulting mechanical 
irritation, due to large, hard protein curds. 

2. Extremes of temperature, heat of summer and cold 
of winter, with resulting systemic depression. 

3. Feeding with infected milk (decomposition products 
of milk and bacterial toxins). 

4. Infections of the gastro-intestinal tract (enteral in- 
fections) . 

(198) 



THE STAGE OF DYSPEPSIA. 199 

5. Systemic infections (otitis, pharyngitis, pyelitis, 
etc.), associated constantly with a lessened tolerance for 
food (parenteral infections). 

6, Congenital lowered tolerance to cow's milk. 

In practice, especially in young infants, frequently we 
do not observe the stage of disturbed metabolic balance, 
because dyspepsia develops directly, due to a relative ex- 
cess of sugar in the food. 

Pathogenesis. We will discuss in detail the second 
group of cases, those due to feeding with a diet of im- 
proper proportions. 

The symptoms of dyspepsia are brought about by in- 
creased acid fermentation, which causes increased peris- 
talsis, and increased intestinal secretion, with resulting 
loss of body fluids. Pathological breaking down of car- 
bohydrates (sugars, flour) is to be regarded with great- 
est probability as primary. It is probable that the fat in 
most cases is involved only secondarily, as a result of the 
increased peristalsis, fermentation, etc. The same 
amount of fat is commonly tolerated perfectly if the 
sugar is lessened sufficiently. It is also probable that 
the fat has an unfavorable influence on the sugar toler- 
ance. That the decomposition products of casein do 
damage to the intestines could not be demonstrated. On 
the contrary, it was found that by sufficient doses of 
casein the pathological fermentation could be combated, 
and thus the casein has a directly curative influence, as 
seen in the tendency to formation of fat-soap stools. By 
reduction or complete withdrawal of carbohydrates the 
pathological fermentation can in almost all cases be de- 
creased, and also the peristalsis, and this seems to prove 
that the carbohydrates are the primary cause of this 



200 INFANT FEEDING. 

condition. The different carbohydrates show different 
tendency to fermentation. Milk-sugar ferments most 
easily, less easily the cane-sugar, and least the dextrin- 
maltose preparations. 

By clinical experiments it was found that the toler- 
ance of even the same intestine towards carbohydrates is 
not always the sq,me, and that it also depends to a cer- 
tain extent upon the quality of the fluid in which they 
are dissolved or suspended. The same amount of sugar 
given with large quantities of whey produces much more 
easily dyspeptic symptoms than the same amount of sugar 
administered in less whey or in water. From this it fol- 
lows that in pathogenesis of dyspepsia of artificially fed 
infants the whey is also of importance, this being in all 
probability due to the quality and quantity of the whey 
salts. 

Symptoms. Dyspepsia is characterized clinically by 
acute gastro-intestinal symptoms, the most marked of 
which are the stools, which are increased in number, and 
of an abnormal quality. The organism does not show 
signs of any deep-seated general changes; weight loss is 
moderate or the weight remains constant. Temperature 
is moderately increased, and repair is rapid with the 
withdrawal of improper food. 

Several general symptoms are usually absent in the 
early stages. The mind is clear. The heart action is not 
rapid. Respirations are not greatly increased. The baby 
is restless and fretful, cries a great deal of the time, 
sleeps brokenly, and sucks its hands and other objects as 
if hungry. The face soon becomes drawn, and the tis- 
sues more or less flabby through loss of body fluids. The 
skin shows little change. Temperature is moderately 
increased. 



THE STAGE OF DYSPEPSIA. 



201 



Weight. The weight loss varies directly with the loss 
of body fluids through the. increased intestinal peristal- 
sis and consequent diarrhea. 



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infant with dyspepsia. 



G astro -intestinal Symptoms. The appetite is poor. 
The mucous membrane of the mouth is red, and may be 
the seat of thrush (due to decreased immunity). Vomit- 



202 INFANT FEEDING. 

ing may be present, and usually occurs long after feed- 
ing. Volatile fatty acids may be detected in the stomach 
content by their odor. The abdomen is distended, and 
peristalsis increased, and is visible or can be heard by aus- 
cultation. Restlessness is marked. 

Stools. The clinical diagnosis is usually made from 
the stools. They are increased in frequency, and they 
also differ from the normal. They are thinner, contain 
more mucus, and are either watery or hashy. There is 
abnormal odor, either that of decomposition or that of 
acid fermentation. The reaction is variable, mostly acid. 
The color of the stool is often green, this being due to 
transformation of bilirubin to biliverdin by oxidizing 
ferments. 

The increased peristalsis results in impairment of ab- 
sorption, which may easily be determined by metabolic 
experiments, and also estimated by macroscopic, micro- 
scopic, and chemical examination of the stools. 

Fatty acids appear in the stools in the shape of white 
or yellowish lumps (milk curd), and, by addition of 
strong acids and slight warming, fatty acid needles may 
be crystallized from them. 

Neutral fat is present in the form of smaller or larger 
drops. 

If flours are in excess, the stools are frequently paste- 
like and foamy. By iodine solutions the unchanged 
starches are stained blue, and the erythrodextrin is 
stained red. 

Of especial interest has been for some time the ques- 
tion whether in stools undigested casein was found. The 
yellowish lumps, the so-called milk-curds, in the hashy 
stools, seen even in feeding with boiled milk, have erron- 
eously been regarded as casein curds, which were sup- 



THE STAGE OF DYSPEPSIA. 203 

posed to escape digestion on account of their being diffi- 
cult of digestion. Today we know positively that these 
so-called "casein curds" are composed chiefly of fatty 
acid salts and bacteria. Only in feeding with raw milk 
frequently large, * tough, bean-like casein curds pass 
through the intestine without being digested. Even in 
the presence of true casein curds, however, one must not 
conclude that they are the primary factors in the patho- 
genesis of this nutritional disturbance unless we are cer- 
tain that an excess of raw milk has been fed. 

Varieties. First, the acute dyspepsia, which begins 
with a definite acute onset, usually in infants who have 
been previously well, and second, a chronic dyspepsia, 
which begins less acutely, or follows acute attacks, and 
which recurs even in the presence of a carefully regu- 
lated diet. It soon becomes evident that in the latter 
cases there is a definite lessening of the food tolerance. 

Diagnosis. The diagnosis can be made only by a 
careful consideration of the feeding history and the clin- 
ical and functional symptoms. 

It is first necessary to differentiate dyspepsia from the 
milder forms of enteral and parenteral infections. The 
latter are frequently associated with intestinal irritation. 
One must remember that the infections, especially in 
young infants, are frequently associated with a second- 
ary nutritional disturbance, and vice versa, that secondary 
infections commonly follow in the wake of nutritional 
disturbances. An infection should be suspected when 
the temperature remains high after the withdrawal or 
reduction of the food (especially of the carbohydrates), 
and when albumin and hyaline casts appear in the urine, 
and the mucus continues in excess in the stools, present- 
ing the picture of a secondary enterocolitis. If infec- 



204 INFANT FEEDING. 

tions are not recognized, there is a great danger of con- 
tinuing the starvation diet (which has been inaugurated 
for the treatment of dyspepsia) too long, and thereby 
reducing the vitality of the infant to the stage of decom- 
position. It is also of importance to note whether the 
dyspepsia is primary or an acute exacerbation in the 
course of a decomposition, as on this differentiation to a 
great extent depends the prognosis and the therapy. 
Here, again, a careful history is of vast importance, and 
one should carefully note the presence of repeated dys- 
peptic attacks, with recurring fluctuations in weight, the 
occurrence of previous infection, both enteral and paren- 
teral, as all of these indicate a tendency to decomposition. 

Prognosis. In infants previously healthy and with 
a proper dietetic treatment, the prognosis is good. Re- 
peated attacks should always be seriously considered. 
Dyspepsia in very young infants is always more serious 
than in the older and better developed ones. 

Treatment. Human Milk. The best treatment of 
all forms of dyspepsia consists of feeding human milk. 
The younger the infant, the more the indication for 
human milk. This is especially true of infants under 
two months of age. In severe cases it may be necessary 
to place the infant on a starvation diet for six to twelve 
hours, and then administer the breast milk in restricted 
amounts. 

Artificial Feeding. In artificial feeding the treatment 
of acute dyspepsia is somewhat different from the treat- 
ment of chronic dyspepsia. 

Acute Forms. In the acute form, where the child was 
previously well and its tolerance good, the simple unload- 
ing of the intestine may allow it to resume its normal 
function. The following treatment is recommended: 



THE STAGE OF DYSPEPSIA, 205 

1. Starvation or Hunger Diet. Short (six to twelve 
hours, rarely longer) starvation, only liquids being ad- 
ministered, tea with saccharin being the best (saccharin, 
1 grain [0.065 Gm.] to 1 quart [1000 mils]). They 
should be given freely, up to amounts of the total fluids 
needed. This permits the stomach and the intestines to 
empty themselves, and to assume their normal functions. 
Laxatives are usually not indicated. If temporary star- 
vation is inaugurated, the intestinal tract soon empties 
itself of its irritating contents. 

2. Indifferent Diet. During the second day in young 
infants, one-third whole milk (best boiled or citrated) 
plus two-thirds thin oatmeal gruel, without sugar, may 
be fed, such a diet being low in food value and salts. 
Buttermilk or skim milk may be used in place of the 
whole milk in severe cases. The total daily quantity of 
the milk mixture on the second day should not exceed 6 
to 12 ounces, divided into six feedings of 1 to 2 ounces 
each. To this, 20 to 25 ounces of tea, plus saccharin, may 
be added, making a total of about 1 quart of fluid for the 
day. This will usually answer. Further treatment de- 
pends on the reaction to the above. Upon this treatment 
the general condition improves, also the disposition, etc., 
and the weight loss ceases in two or three days. When 
this is not the case, decomposition or infection should be 
suspected. 

3. Sustaining Diet. Gradually, and as rapidly as pos- 
sible, the food should be increased, the increase to be 
made at least every other day, in order to limit the under- 
feeding to minimum. By the third day the quantity of 
the milk mixture should be increased, the quality may be 
left unchanged, giving water or tea to the necessary 
quantity of fluids between the feedings. Weight increase 



206 INFANT FEEDING. 

should not be expected because of the low sugar content 
and low caloric value of the diet, but a decrease in weight 
should always be considered serious. The stools are at 
first small and contain mucus, later less frequent, and 
often on milk mixtures without sugar there are fat-soap 
stools which are a good indication. 

4. Ordinary Diet. In mild cases, the ordinary milk 
mixtures proper for the given infant may usually be re- 
sumed by the end of a week. In more severe cases, re- 
turn to a full diet should be slower. In these mixtures, 
the carbohydrates should be started with 1 per cent, of 
the whole mixture, and gradually increased to 5 per cent. 
The carbohydrates most suitable for this purpose are the 
maltose-dextrin compounds, especially those with a high 
dextrin content and no potassium carbonate. In older in- 
fants cereals in the form of flour ball, barley flour, farina, 
zwieback, can often be added to advantage, as well as 
clear broths. At first there is a rapid increase in weight, 
later on a slower one. 

Avoid underfeeding too long, even if the stools look 
bad, if the temperature and weight curves improve, be- 
cause of the danger of decomposition. It should be borne 
in mind, therefore, that it is undesirable to underfeed for 
a long period, and more especially dangerous to inaugu- 
rate starvation repeatedly, or to keep an infant for days 
on a starvation diet, such as cereal waters or very weak 
milk mixtures. It is also necessary to know and recognize 
the stools of an underfed infant (hunger stool). This is 
greenish-brown in color, composed chiefly of mucus, and 
small in amount, and sometimes frequent. They should 
not be mistaken for the curd-containing frequent stools 
of dyspepsia, as the former is an indication for the re- 
sumption of food, while the latter indicates starvation. 



THE STAGE OF DYSPEPSIA. 207 

Fats can be added in place of sugars, but this should be 
done with care. Codliver oil has given us the best re- 
sults. It should be given in small quantities at first, be- 
ginning with 1 mil twice daily, and increased to 4 mils 
per dose. 

In some infants the above-described treatment is un- 
successful. In one group of these cases the loss of 
weight is not favorably influenced, while the stools im- 
prove; and in a second group the loss continues with 
continued diarrhea. In these cases there is either infec- 
tion or they are cases of grave nutritional disturbances on 
transition to decomposition. It would be a very great 
mistake to continue starvation longer, with the idea that 
by giving the digestive tract longer rest, it may still re- 
cover. This may kill the child. In these cases treatment 
as recommended for decomposition or infection must be 
instituted. Therefore, it is advisable to use routine 
treatment as described above, and, if not successful, the 
underfeeding should not be continued under any circum- 
stances, but the treatment for decomposition (described 
later) or infection (see Infections) should at once be in- 
stituted, if human milk is not obtainable. 

It is in these cases that Finkelstein's albumin milk is 
indicated. (See p. 292, for preparation, and p. 236, for 
method of administration.) 

Chronic Cases. In treatment of chronic forms there is 
no indication for underfeeding. Since here there is no 
transitory weakness, but a chronic weakness of tolerance, 
the additional trauma of starvation would have an un- 
favorable influence. Carbohydrates are to be reduced 
to the amounts absolutely necessary (about 2 to 3 per 
cent), and the less easily assimilable carbohydrates are to 
be replaced by those that are more easily assimilated 



208 INFANT FEEDING. 

(maltose-dextrin mixtures). If this does not improve 
the stools, then nursing on the breast or albumin milk 
feeding is necessary. If both of the latter are not avail- 
able, then the quantities of foods should be carefully 
measured, with the hope that when the child becomes 
older the tolerance will become physiologically increased, 
and the condition thereby undergo spontaneous healing. 

Medicinal Treatment. This is unnecessary in most 
cases. For the treatment of irritative conditions which 
persist even after the dyspepsia proper (loose stools in 
presence of gain in weight), astringents are of use. 
Tannigen or tannalbin 1 to 5 grains (0.065 to 0.325 Gm.) 
four to five times daily will answer, or calcium lactate in 
doses of 10 to 15 grains (0.65 to 1 Gm.) may be pre- 
scribed in a 10 per cent, solution to be added to each milk 
feeding. 



CHAPTER V. 
THE STAGE OF DECOMPOSITION. 

Synonyms: Marasmus, atrophy, pedatrophy. 

The third stage of impaired nutrition in the classifica- 
tion of Finkelstein, called by him decomposition, is recog- 
nized by him as what has been described in pediatric 
literature as marasmus or atrophy. The clinical picture 
may be viewed as the end result of repeated nutritional 
disturbances or constitutional factors. The past history 
is of the utmost importance, and a careful search reveals 
improper diets, with resulting disturbance of nutrition, 
or a nutritional disturbance following enteral or paren- 
teral infections, each leaving in its wake evidence of im- 
paired nutrition, until after weeks or months we have 
reached the stage of deep-seated tissue starvation. The 
chronic infections, such as syphilis and tuberculosis, may 
also result in a similar picture, but must be differentiated 
to clear the classification for therapeutic purposes. 

During this stage it becomes increasingly difficult for 
the infant to assimilate a sustaining diet, with resulting 
extreme loss of weight, and great lack of resistance of 
the organism to infections and other injurious external 
influences (heat, cold), this general weakening of the 
vitality of the infant being due to perverted metabolism, 
consisting of breaking down of the body substance, and 
change in the composition of the cells (abnormal kata- 
bolism), and of deficient and improper assimilation of 
the food (abnormal anabolism). 

Etiology. Disturbed metabolic balance may be the 

14 (209) 



210 INFANT FEEDING. 

direct forerunner of decomposition, if the dietetic error 
is not corrected ; likewise all factors leading to dyspepsia 
and intoxication may also be forerunners of decomposi- 
tion. At what moment this change takes place we have 
no means of telling, but we know that deep-seated organic 
changes are necessary to its development; these changes 
which produce such an intolerance toward nourishment 
may have developed previously to the preceding illness, 
or during its course. Premature infants are especially 
predisposed, also young infants with previous dietetic 
errors and diarrheal attacks, also those fed on a one- 
sided diet, excessive in carbohydrates, especially cereal 
waters and gruels, as seen in too long continued hunger 
diet. Especially to the very young does the statement as 
to cereal waters and gruels apply. All of the preceding 
reduce the tolerance toward assimilation of a full and 
normal diet. The tendency to decomposition, and there- 
fore to the narrowing of the nutritional sphere increases 
with each dyspeptic attack. Czerny's internal hunger, or, 
as he commonly calls it, "cell hunger," is the cause of de- 
composition. The above term is used in contradistinc- 
tion to hunger as usually thought of, which is due to a 
lack of food to appease the appetite. 

Pathogenesis. In the older literature the terms 
marasmus and atrophy were used to describe the clin- 
ical picture as presented by this condition. And it was 
assumed that destructive changes in the intestinal glands 
following chronic inflammation, with a secondary impair- 
ment of the functions of absorption and excretion, were 
the underlying pathological conditions, which resulted in 
an inanition. This, however, has been found to be erron- 
eous, since repeatedly the intestine of the atrophic infants 
was found to be normal. 



THE STAGE OF DECOMPOSITION. 211 

The great and sudden fluctuations in weight as seen in 
this condition must in the first place be due to loss of 
water and salts, while the disintegration of the body sub- 
stance, including the cells, furnishes only a smaller quota 
to the loss of weight. 

The researches of Czerny on metabolism have thrown 
considerable light on this condition. The abnormal split- 
ting of sugar and fats contained in the food produces ex- 
cessive amounts of acids in the intestines, which results 
in the loss of alkali salts, first, through neutralization 
of the acids formed in the intestinal tract from the food, 
and secondly, through salt losses due to excessive intes- 
tinal secretion, as seen in this condition. These abnormal 
processes result in a relative acidosis, an acidosis of en- 
teric origin. And as a result of such, enteral loss of 
salts and markedly increased NH-excretion takes place, 
which is evidenced clinically by increase of ammonia in 
the urine. 

To cover these losses, salts deposited in the tis- 
sues are in part withdrawn, and finally the cells them- 
selves are destroyed through being deprived of their 
salt content (mineral hunger). It should be remem- 
bered that an abnormal fat metabolism is frequently the 
essential factor in the etiology of this condition, due to an 
overstepping of the fat tolerance. And further that 
fermentative changes in the carbohydrates produce in- 
creased acidity of the contents of the intestinal canal, 
and so enhance the action of fats. While there is usually 
an excess of protein loss over protein assimilation, the 
tolerance for proteins is usually less affected. Because 
of the loss of nitrogenous substances due to a relative 
excess in excretion of NH, proteins must be utilized in 
the diet to counteract these losses. 



212 INFANT FEEDING. 

Increased peristalsis in diarrheal conditions results in 
further inanition, due to the passing of undigested food 
through the intestinal tract. The "decomposition" of 
the organs essential to life finally leads to an alteration 
of the condition of the cells and of their functions, which 
results in the death of the organism. 

Symptoms. The cardinal symptoms of decomposi- 
tion are intolerance to food and great loss of weight. 

1. Lack of ability to assimilate food is pathognomonic 
of this condition. The paradoxical reaction to food, 




Fig. 11. — Infant with decomposition. 

mentioned in the two preceding stages of nutritional dis- 
turbances, becomes here a striking and serious phenom- 
enon. Starvation or the institution of the hunger day as 
a therapeutic measure in these infants not infrequently 
results in an inanition which is fatal to the infant. 
Again, too rapid increases in the diet are equally serious, 
and not infrequently precipitate alarming and fatal symp- 
toms. When the condition has progressed to this degree, 
human milk alone offers hope of recovery. 

2. Loss in weight is the second cardinal symptom of 
decomposition, due, as the name of this condition sug- 
gests, to disintegration of the body substance. This may 
be slight in the beginning, and in the light cases ; in the 



THE STAGE OF DECOMPOSITION. 



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214 INFANT FEEDING. 

later stages and in severer cases, however, it is often 
sudden and rapid, and may reach daily losses from 1 to 
3 ounces (30 to 100 Gm.), resulting eventually in a pic- 
ture of marasmus. The baby becomes thin, emaciated, 
wrinkled, with prominent ribs, covered with tightly 
drawn skin, and with intercostal spaces deeply marked 
(skeleton-like). The tissues are soft and flabby, the 
muscles either relaxed or hypertonic, the abdomen pro- 
tuberant, usually distended, the color, pale first, later 
changing to characteristic grayish-white, with more or 
less cyanotic lips, fingers and toes. The mouth appears 
large, the cheeks sunken, and the facial expression 
anxious and serious. These characteristics give the in- 
fant the appearance of a wrinkled old man. As has been 
previously stated, in the earlier stages, these babies are 
irritable and apparently in constant distress, cry a great 
deal, and are excessively hungry. In the later stages, 
however, they are often apathetic, and apparently too 
weak to perform voluntary movements. When they 
have reached this stage, they are subject to sinking spells 
— that is, periods in which their vitality is very low. 
These may become very alarming, and often result 
fatally. 

3. Vomiting is frequent. 

4. The hunger is often very great, and extremely diffi- 
cult to satisfy. 

5. Subnormal temperatures, ranging from 96° to 
98° F., w T ith an irregular daily curve is the rule. The 
temperature can easily be raised to 100° or more by the 
application of artificial heat (hot water bottles, etc.), 
and can sink quite as rapidly and alarmingly when the 
artificial heat is removed. 



THE STAGE OF DECOMPOSITION. 215 

6. The pulse is often slow and small, and the heart- 
beats weak, and often only one heart tone is heard at 
the apex. 

7. Respiration becomes rapid, and the expirations pro- 
longed. The breathing becomes irregular, even to the 
Cheyne-Stokes type. 

8. The sensorium is not involved in these infants, and 
when not too weak they take cognizance of their sur- 
roundings, are alert, and sleep but little. 

9. The urine usually shows an increased ammonia out- 
put. It may contain albumin, but very rarely sugar. 

10. The stools are variable, mostly dyspeptic, occa- 
sionally diarrheal. In the earlier stages and in periods 
of remissions they may be quite firm (soap stools), again 
soft and firm stools may alternate. The hunger stool — 
small, dark, and containing much mucus — is common, 
especially in advanced cases, with an inability to take 
proper diet. Dark-brown, black, and tarry stools indi- 
cate usually hemorrhages from ulcers in duodenum 
(Helmholtz). We therefore learn to recognize the char- 
acter of the stools as being only of secondary importance 
in the diagnosis, and also of secondary importance for 
treatment. We must not be misled into further starva- 
tion because of temporary changes in character, even for 
the worse, of the stool, due to the changes in the diet 
instituted for therapeutic purposes. 

11. These infants are peculiarly susceptible to infec- 
tions, and even slight infections of the skin, respiratory, 
gastro-intestinal, and genito-urinary tracts may prove 
fatal. 

12. Edema, cyanosis, and a more or less generalized 
purpura are not infrequently forerunners of an impend- 
ing death. 



216 INFANT FEEDING. 

Diagnosis. The diagnosis in severe cases may be 
made from the clinical picture of the condition, but it is 
necessary to exclude emaciation due to tuberculosis, 
syphilis and cachexia caused by other disease, and also 
by simple inanition, due to prolonged underfeeding. This 
is to be based on the history and examination of the in- 
fant. In lighter cases it is necessary to differentiate espe- 
cially from disturbed metabolic balance and from simple 
dyspepsia, since the treatment which improves these con- 
ditions may do considerable harm in infants suffering 
from decomposition. The status prsesens is not sufficient 
for making the diagnosis, since, as previously mentioned, 
remissions with stationary weight and good stools often 
occur. In these cases the history is of utmost impor- 
tance: repeated diarrhea, loss in weight and febrile in- 
fections should lead one to suspect decomposition. The 
positive diagnosis is made upon the reaction of„ the in- 
fant to food. If on somewhat increasing the diet a 
marked and severe paradoxical reaction appears (diar- 
rhea, loss of weight, and occasionally fever), decomposi- 
tion should be suspected. 

Prognosis. We must remember that while primarily 
the picture of the disease is a nutritional one, the death 
is frequently brought about by infection. 

The prognosis depends on the following factors: (1) 
The stage of decomposition. When the loss of weight 
has reached one-third of the body weight (Quest's fig- 
ure), then the reparation under any treatment seems to 
be impossible. (2) The nature of the dietetic treatment, 
and especially the possibility of feeding with human milk. 
If one avoids the common errors, even the severe cases 
may be saved, except when the treatment is started too 
late. (3) The extent of the lowered immunity. The 
prognosis should always be guarded. 



THE STAGE OF DECOMPOSITION. 217 

Improvement is common even in severe cases, but there 
is a great tendency to sinking spells and collapse. Death 
in these cases is sometimes remarkably sudden. It usu- 
ally occurs in one of the following ways: (1) By sud- 
den syncope. (2) By apparent paralysis of the respira- 
tory center. Periods of apnea usually precede the latter. 
There is no disturbance of consciousness. The face looks 
gray, and the eyes are staring. The breathing becomes 
irregular and slow, the heart weakens, the temperature 
sinks far below normal, cyanosis increases, and breath- 
ing gradually stops. Sometimes the heart stops first. 
Such death may extend over days. 

Treatment Prophylaxis is the key-word to success- 
ful treatment. A recognition and proper interpretation 
of minor nutritional disturbances will avoid the graver 
conditions. 

For a proper conception of the therapeutic needs we 
must recognize: 

1. That we have a chronic condition which is subject 
to acute catastrophes. 

2. That the younger the infant and the greater the pre- 
ceding dietetic errors, the graver are the consequences 
of decomposition. 

3. That starvation is dangerous. 

4. That food is assimilated with difficulty. 

5. That the downward weight-curve is likely to drop 
suddenly with improper feeding and intercurrent in- 
fection. 

Two essentials are necessary to the successful treat- 
ment of the majority of cases of decomposition: (1) 
avoidance of prolonged starvation, and (2) human milk. 
It is the misfortune of most of these infants to have 
their abnormal stools, or more commonly, the hunger 



218 INFANT FEEDING. 

stools previously described, interpreted as an indication 
for starvation, regardless of the fact that the baby is 
already starving. It has been our experience not only 
to have seen one day of starvation, but repeated periods 
of starvation the rule, because of misinterpretation of 
the significance of the "starvation stools." A single day 
of starvation is often sufficient to kill an advanced case, 
and even prolonged underfeeding, below 60 calories per 
kilogram (the amount required to sustain the body 
equilibrium), has a very harmful effect. Starvation from 
without is thus added to inanition, from within. 

1. Feeding with Human Milk. It must be given in 
moderate quantity, best guarded by drawing off and 
feeding, as these infants drink too rapidly (always hun- 
gry), and do not stand large amounts. About 200 to 
300 mils daily is enough to sustain the infants tempor- 
arily (70 calories per kilogram is sustaining — Rosen- 
stern). Feed often; ten feedings may be given, one 
every two hours (10 to 20 mils), weak tea or saccharin 
water ad libitum between feedings. The daily quantity 
should be increased as rapidly as possible (at least every 
other day), until not later than after 7 to 10 days about 
100 calories (130 to 150 mils) per kilogram are admin- 
istered. The number of feedings should gradually be 
decreased as the condition improves, and direct nursing 
on the breast may be tried later, but the danger of over- 
feeding must not be overlooked. 

Weight may still not improve for some time. This 
Keller calls "reparation stage!' Even on feeding with 
human milk there is a shorter or a longer period of 
stationary weight (depending on the severity of the 
case), which, however, is accompanied by improvement 
of the symptoms, Those who have not had experience in 



THE STAGE OF DECOMPOSITION. 219 

these cases may be inclined to blame the wet-nurse, and 
advise a change. This, however, is constant in the stage of 
reparation, in which the body is being reconstructed, with- 
out being able to put on weight, this being partially, at 
least, due .to still deficient absorption, and partially also 
to the fact that the human milk, containing comparatively 
small quantities of proteins and salts, furnishes only a 
limited quantity of material for rebuilding of the body. 
Only after this period the gain in weight begins. This 
may be shortened by feeding daily 100 mils of boiled 
buttermilk or skim milk, which is rich in salts and pro- 
teins, both of these substances hastening weight increase. 
This is not to be done until after the third or fourth 
week of treatment, and with a close observation of the 
results. It may be fed by mixing with and distributing 
through the breast feedings. 

Carbohydrates should be added with even greater care, 
adding 4 Gm. at a time to the day's feeding. In older 
infants a small amount of farina soup or zwieback in tea 
may be tried later. 

The complete recovery is not to be expected sooner 
than in two to three months. And only then should the 
return to artificial feeding be thought of. The weaning 
should be preceded by experimental administration of 
small quantity of whole cow's milk, as there is a possibil- 
ity of idiosyncrasy to cow's milk. 

2. Artificial Feeding, If there is no possibility of 
feeding an infant suffering from decomposition other- 
wise than with artificial food mixtures, then the same 
rules are to be followed as have been given for dyspepsia. 
In this condition also the first thought should be of boiled 
buttermilk and skim milk mixtures, with a low percent- 
age of fat, diluted with gruels, and containing a moder- 



220 INFANT FEEDING. 

ate quantity of slowly fermentable carbohydrate, such as 
maltose-dextrin compounds (see Appendix), fed in small 
quantities at frequent intervals. 

In mild cases feedings of 30 mils (1 ounce) 8 times 
daily, and in severe cases 10 or 12 feedings of 15 mils 
(0.5 ounce), may be given in the twenty-four hours. 
The buttermilk can be replaced by skim milk, if the 
former is not well taken. Flour ball or dextrinized barley 
flour can be used in place of ordinary wheat flour to ad- 
vantage, and maltose-dextrin compounds can be used in 
place of cane-sugar. 

Brady's mixture No. 1 can frequently be used to bet- 
ter advantage in the same quantities (see Appendix, 
p. 286). 

The individual meals should be increased so as to 
meet the infant's caloric needs as rapidly as the condi- 
tion allows. 

While in simpler forms of nutritional disturbances the 
intestine recovers within a short time to such an extent 
that the feeding may be more liberal, in severe decom- 
position the increase of food is often followed by aggra- 
vation of the condition. Administration of farinaceous 
foods alone is also risky, because of the danger of fur- 
ther inanition. From this it becomes apparent how 
limited is the outlook for good results in the extreme 
cases of this condition with artificial feeding, especially 
when occurring in very young infants. 

Recent experience, however, has taught us that the 
boundaries of curability can be considerably broadened 
by the use of the albumin milk of Finkelstein. The ob- 
ject of the albumin milk is to limit as much as possible 
the injurious acid fermentation, which is accomplished 
by diminution of the percentage of milk-sugar below that 



THE STAGE OF DECOMPOSITION. 221 

contained in cow's milk, by the removal of some of the 
whey, whereby the tolerance of the intestine for the 
sugar is improved. By the administration of large 
amounts of finely divided casein as contained in the 
albumin milk, alkaline reaction is produced which is 
antagonistic to acid fermentation. It also contains over 
2 per cent, of fat, which can be digested by these infants 
in all probability because of the small quantity of sugar 
and salts contained in the albumin milk. 

The advantage of the treatment with albumin milk 
consists in the fact that it is possible to reach sufficient 
feeding quantities much more rapidly than with most 
other artificial foods, without the danger of exciting 
anew the fermentative processes. Thereby the danger 
of inanition is avoided and reparation is accelerated. 

In the mild cases of decomposition we start after an 
interval of six hours on tea, with administration of 300 
mils of albumin milk, with an addition of 3 per cent, of 
maltose-dextrin preparations (milk-sugar is not advis- 
able, and even the cane-sugar is not so reliable), divided 
into 5 or 6 meals, and with further addition of tea. In 
the days that follow, without paying any attention to the 
stools, the quantity of albumin milk is increased, every 
other day by 100 mils. In the presence of firm stools it 
is increased even more rapidly, until a daily quantity of 
180 to 200 mils per kilogram (3 ounces per pound body 
weight) is reached. A total daily quantity of 1000 mils 
of albumin milk is rarely to be exceeded. In typical 
cases dry fat-soap stools appear after one to two days, 
this is followed by cessation of weight loss, and repara- 
tion proceeds undisturbed. 

After the quantity of food necessary to sustain the 
infant is reached, sugar may be gradually increased from 



222 INFANT FEEDING. 

3 to 5 per cent. Dextrinized starches in the form of 
flour ball (imperial granum), or dextrinized barley flour 
in quantities of 1 or 2 per cent, of the mixture, can often 
be added to advantage to albumin milk before adding 
sugars. 

In severer grade of decomposition the intestine is also 
to be evacuated by a short period of hunger. In spite 
of the danger of inanition, six, or at most twelve, hours 
on tea cannot be avoided. This is to be followed by the 
administration of albumin milk, best with frequent meals 
(8 to 10), on the first day 200 to 300 mils, and then, as 
previously advised, rapid increase with gradual diminu- 
tion of the number of meals and increase in the addition 
of carbohydrates. If the initial loss in weight does not 
stop within three to four days, and if the child 
shows languor and tendency to subnormal temperature, 
then the addition of carbohydrates must be increased, 
even in the presence of frequent stools, until the loss 
stops. 

If we proceed in this way, then the number of unsuc- 
cessful cases becomes considerably smaller. Experience 
has shown that in albumin milk therapy often an error 
is made which frequently leads to failure by underfeed- 
ing. It should be remembered that albumin milk has a 
caloric value of only about 12 to the ounce, and therefore 
this feeding must be carefully guarded to avoid (1) too 
slow initial increase, thereby prolonging inanition, (2) 
omission of carbohydrates or insufficient increase of the 
same, (3) repeated restriction of the quantity of the 
food, or withholding carbohydrates when the temperature 
rises or diarrhea reappears. All these are to be avoided. 
Only when sudden loss in weight and violent diarrhea set 
in, should the total quantity of the food be reduced. 



THE STAGE OF DECOMPOSITION. 223 

After disappearance of these acute symptoms the increase 
must be made as soon as possible. 

In the beginning of the treatment with albumin milk, 
exacerbations similar to those that occur on feeding with 
human milk may occur, and these should not lead to 
starvation. Later, the gain is rapid, provided that suffi- 
cient quantities of carbohydrates have been added. 

The duration of feeding with albumin milk is about 
six to eight weeks for the younger infants, and four to 
six weeks for the older infants. After this time the dis- 
ease is cured usually to such an extent that ordinary milk 
mixtures, corresponding to the child's age and weight 
may well be taken. The change is best made by replacing 
all the feedings of albumin milk mixtures at one time. 
This is frequently followed by bad stools for a day or 
two, which should not lead one to discontinue the new 
diet. The quantity, however, should not be further in- 
creased until they show some improvement. 

If a relapse occurs, then it is necessary to return to 
feeding with albumin milk for some additional time. 

One may speak of a complete cure of this nutritional 
disturbance in an infant only when, after discontinuation 
of albumin milk and return to the usual milk mixtures, 
with careful dosage, the development proceeds without 
any disturbance. 

Medicinal Treatment. This is practically limited to 
stimulation in the presence of collapse and sinking spells, 
and the favorite stimulant is camphor given intramus- 
cularly in the form of a sterilized camphorated oil (5 to 
10 drops every two to four hours). Alcohol is appar- 
ently of benefit in severe cases. Five to 15 drops of 
whisky or brandy every two to four hours. In the 
severer types transfusion is also indicated. 



224 INFANT FEEDING. 

Artificial heat must be applied in all cases with a de- 
cided tendency to low temperatures. This must not be 
overdone, since the child's temperature can easily be 
raised above the normal, and act as unfavorably as sub- 
normal temperature. 



CHAPTER VI. 
THE STAGE OF ALIMENTARY INTOXICATION. 

Synonyms. Gastroenteric intoxication (Holt), catar- 
rhal enteritis, ileo-colitis, toxicosis, infectious diarrhea, 
cholera infantum, summer diarrhea. 

Definition. This is not a disease, but a general toxic 
state, characterized by a symptom-complex in which diar- 
rhea and irritability of the central nervous system are 
the most characteristic signs of the toxemia. 

The graver the preceding nutritional disturbances, i.e., 
the closer the infant approaches the stage of decomposi- 
tion, the more readily does the stage of intoxication de- 
velop. Collapse and nervous symptoms outweigh the in- 
testinal symptoms. 

Etiology. All factors which cause nutritional disturb- 
ances can be active factors in the causation of intoxica- 
tion. Although frequently a primary food disturbance, 
it is more commonly seen as a food disturbance secondary 
to some other factor. Among the most important of 
these are: 

1. Food. 

(a) Combination of food elements which individ- 
ually would be insufficient to cause a dis- 
turbance. 

(&) Infected food — that is, spoiled milk, not com- 
monly due to the bacteria themselves, but to 
their activity on the fats and sugars, and the 
formation of toxic bodies (Czerny and 
Keller). 

2. Infections. They are not due to a single factor. 
We must believe that the infections injure the intestinal 

15 (225) 



226 INFANT FEEDING. 

wall and other digestive organs. From this point the 
pathogenesis is the same as in alimentary intoxication. 
The toxic influences of different infections are as differ- 
ent as are the infections. 

(a) Gastro-intestinal infections (enteral infection). 

(See chapter IX.) 

(b) Systemic infection, as otitis, cystitis, pharyn- 

gitis, etc. (parenteral infection). Intoxica- 
tion is frequently seen following in the wake 
of or occurring during infections due to the 
disturbances in the digestive functions. (See 
chapter IX.) 
3. Heat. This can cause a chain of symptoms re- 
sembling intoxication. As to the exact cause there has 
been much speculation, and it is not yet satisfactorily 
settled. We cannot overlook the fact that in many cases 
a chain of symptoms resembling intoxication is seen, 
seemingly due to bacterial action on the milk, and the 
subsequent production of toxic bodies. 

These facts are established: that infants are greatly 
depressed and debilitated by heat, and therefore can 
stand less food in the hot months. It is also true that 
less food is required during the summer months to nour- 
ish an infant, and this should be taken advantage of as 
a prophylactic therapeutic measure. Unfortunately, this 
is not heeded in many cases, because the child is more 
thirsty, and, its food being liquid, quenches its thirst, 
and is therefore given in excessive amounts; and sec- 
ondly, because the cry and discomfort due to the same 
overfeeding and heat are interpreted as hunger. It 
should therefore be the duty of the physician to warn 
against excessive feeding during the hot summer months ; 
that these latter are factors is evidenced by the fact of 






STAGE OF ALIMENTARY INTOXICATION. 227 

their prevalence among the poor and ignorant. Summing 
up the situation, we can state with positiveness that all 
depends upon the individual resistance; a more severe 
irritant is necessary in those suffering with disturbed 
metabolic balance and dyspepsia than in the atrophic in- 
fants to develop the stage of intoxication. 

To recapitulate : to develop intoxication there must be 
a pre-existing nutritional disturbance or an injured in- 
testinal epithelium. Enteric and systemic infections, as 
well as heat, predispose to intoxication through their 
action on the cells of the digestive apparatus of the in- 
testinal and secretory glands, and general systemic effect. 
The resemblance of these cases to an infection naturally 
leads to the belief that they are due either to infection of 
the intestinal mucous membrane or to the absorption of 
bacterial toxins from spoiled milk. While infections or 
toxins may cause a similar picture, in a large group of 
cases they will not explain the clinical findings — first, be- 
cause the symptoms disappear upon withdrawal of the 
food; secondly, they may appear during the feeding of 
aseptic milk as well as septic, and that no pathological 
findings are found that could explain the symptoms. 
Again, increases of food above the child's tolerance will 
cause relapses, and food withdrawal will again cause a 
rapid improvement. 

Pathogenesis. Several factors, either individually 
or together, can cause the group of symptoms charac- 
teristic of alimentary intoxication. 

1. The symptoms may be due to the toxicity follow- 
ing absorption of imperfectly elaborated products of the 
intermediary metabolism. These are the type of cases 
described by Finkelstein in his "Food Injuries/ , and rep- 
resent the fourth stage in the progressive intolerance for 



228 INFANT FEEDING. 

food. The less the infant's tolerance, i.e., the closer it 
approaches the stage of decomposition, the smaller the 
amount of food necessary to produce an intoxication 
(Finkelstein). The precipitating factors are the same 
as in dyspepsia — that is, the sugar and whey (lactose and 
salts) content in the food — but here we have a more 
severe picture. The alimentary glycosuria, which fre- 
quently occurs, is evidence of a disturbance in the carbo- 
hydrate metabolism. Sugars of the type ingested may 
be seen in the urine long before the end of the proper 
assimilation period. This ceases when the sugar is with- 
drawn from the diet. Fat can also produce toxic symp- 
toms, but this can in all probability occur only after the 
sugar has acted harmfully, or when the infant is in or 
approaching the stage of decomposition, or after a severe 
infection has seriously affected the infant's metabolism. 
This in turn, together with the hunger and loss of alka- 
lies due to vomiting and diarrheal stools, may bring 
about an injury to fat metabolism which may be evi- 
denced as an acidosis. Meyer found fat absorption -re- 
duced from 97 to 60 per cent. This improves early in 
convalescence. Splitting of fats is bad, and we get an 
acidosis with the presence of acetone and aceto-acetie 
acid, butyric acid, etc., in the urine (Rosenstern). When 
this stage is reached, there is also another probability — 
that of interference with protein metabolism ; but whether 
or not this has any effect upon the picture rendered by 
intoxication is open to question. It is questionable 
whether the salt loss is the primary cause of the water 
loss, or whether the loss of water by the system has its 
own pathogenesis. Indeed, it would require a great salt 
loss to account for the great loss of water, and it is quite 
possible that a toxic influence results in a disturbance of 



STAGE OF ALIMENTARY INTOXICATION. 229 

the water-binding property. The great water loss also 
causes accumulation of toxic products and products of 
metabolism in concentrated solutions. 

In such a general failure of metabolism, we have to as- 
sume a severe damage of the corresponding organs and 
cells. We have, therefore, when the picture is complete, 
an insufficiency of all the functions of the intermediary 
metabolism (metabolic bankruptcy — Finkelstein) . 

2. The symptoms may be due to a relative acidosis 
dependent upon an excessive loss of bases, more espe- 
cially sodium, by way of the alimentary tract, through 
vomiting and the diarrheal stools. This is evidenced 
clinically by the increased ammonia content of the urine. 
From 40 to 50 per cent, of nitrogenous compounds of the 
urine do not appear as urea, but as ammonia, the am- 
monia being used to unite with the acids which are in 
relative excess in the blood. Howland and Merriet 
found in their investigations of toxic diarrheas that not 
alone was the acidity of the blood increased, but that 
there was a positive evidence of acidosis, as shown by the 
diminution of carbon dioxide tension of the alveolar air. 
They also found an increased tolerance for alkalies in 
these infants, in which they resemble other forms of 
acidosis. 

3. The type secondary to the enteral and parenteral 
infections. In this group, two further factors are of im- 
portance — first, that due to bacterial invasion in the infec- 
tions; and second, the danger of absorption of the toxic 
products of bacterial fermentation of food in the intes- 
tinal tract. 

Even in the infective types, the several factors, ab- 
sorption of toxic products of the intermediary metab- 
olism, the relative acidosis due to alkali losses through 



230 INFANT FEEDING. 

the stools, and, lastly, the absorption of toxic products 
from the intestinal canal, may all be constituting causes. 

4. The large group of cases seen during the hot sum- 
mer months are probably due to a combination of factors, 
— systemic depression, spoiled milk and bacterial invasion. 

We have, therefore, a clinical picture dominated by 
nervous and intestinal symptoms which may be caused 
by a variety of factors. The manifestations may be the 
end result in the cause of chronic nutritional disturb- 
ances, with a steady tendency toward metabolic bank- 
ruptcy, or, as in the case of the third and fourth groups, 
the effect may acutely follow the absorption of products 
of bacterial fermentation from the intestinal tract in in- 
fants often previously strong and healthy. In all of 
them a secondary relative acidosis due to salt losses 
through vomiting and diarrhea is a serious complication. 
Again, it may be quite impossible to decide in many cases 
whether the products of intermediary metabolism, the 
secondary relative acidosis, or the toxic products of bac- 
teriological fermentation are the most important factor in 
the causation of the clinical manifestations on the part 
of the nervous system. 

Symptoms. 1. Fever. A rise in temperature is the 
first symptom of an alimentary intoxication. It may be 
slight, or it may go up to 104° or even 106° F. The 
height of the temperature is not always a direct indica- 
tion of the severity; in fact the several types associated 
with decomposition may have a low temperature. If the 
case be one of true intoxication, prompt withdrawal of 
the food is usually as quickly followed by a lower tem- 
perature. However, if the offending food is continued, 
we soon have other symptoms suddenly and to an alarm- 
ing degree. 



STAGE OF ALIMENTARY INTOXICATION. 231 




232 INFANT FEEDING. 

2. Rapid loss in weight, even 1 to 2 pounds in a few 
days. This is mainly due to loss of water. The skin be- 
comes dry and inelastic. 

3. Vomiting is frequent, and may contain blood. 

4. The stools are liquid, usually numerous, and con- 
tain mucus, and occasionally blood. In the severest cases 
■ — cholera infantum — the stools assume a rice-water ap- 
pearance, move almost continuously, and are often asso- 
ciated with tenesmus, and not infrequently prolapse of 
the rectum. Exceptionally, an obstipation is seen in 
place of the diarrhea, and when this is associated with 
vomiting and abdominal distension one cannot help but 
think of intestinal obstruction. 

5. Collapse. The skin is gray in hue, and becomes 
wrinkled. The eyes are sunken, with distant stare, and 
the nose assumes a pinched appearance. 

6. Nervous symptoms and psychic disturbances are 
usually pronounced, and often lead to a confusion with 
meningitis. The infant is restless; the sensorium is dis- 
turbed, with an occasional cry as if in pain; the hydro- 
cephaloid state may be present, with strabism, convul- 
sions, etc. Before these more severe symptoms develop, 
the child appears apathetic, drowsy, and dopy. The face 
assumes a fixed expression, and there is a tendency on 
the part of the infant to lie constantly in one position, 
and when the child moves its extremities it does so 
slow'ly, as if too tired or weak to change its position. 
The arms are not infrequently flexed in an attitude re- 
sembling that of a prize fighter. If the condition in- 
creases in severity, stupor and coma, associated with 
twitchings, convulsions, strabismus, and other meningeal 
symptoms, ensue. 



STAGE OF ALIMENTARY INTOXICATION. 233 

7. Typical respirations (deep, rapid, without pause), 
described as toxic respirations. The respiratory mani- 
festations may vary from a slight increase in number and 
depth to a marked dyspnea. 

8. Glycosuria is a frequent finding in the type due to 
"food injury/' and the sugar is of the same variety as 
that in food; thus, milk-sugar leads to lactosuria and 
galactosuria. This glycosuria, which is of alimentary 
origin, disappears with the withdrawal of the food. The 




Fig. 14. — Infant with intoxication. 

phenylhydrazin test is the most reliable to make, as the 
copper sulphate tests require long boiling with lactose, 
etc., and the reaction may be overlooked. 

9. The urine contains albumin and casts. The amount 
of urine is small, even to anuria. 

10. Leukocytosis is present up to 30,000. 

11. The heart action is weak, and the pulse small and 
irregular. 

12. Sclerema is constantly seen in the severer types — 
a very bad sign — due to a coagulation of tissue fluids of 
an unknown nature (Czerny and Keller). 

13. Enlargement of the liver accompanies the severe 
types. 



234 INFANT FEEDING. 

Pathology. In the small intestine there is usually 
no marked change. Hyperemia of the mucous mem- 
brane and enlarged follicles, especially Peyer's patches, 
are usually present. The liver shows a hyperemia, 
cloudy swelling, and fatty degeneration (probably caus- 
ing hepatic insufficiency). 

Diagnosis, The diagnosis is based on the above 
symptoms, and improvement on withdrawal of food. 
The most characteristic and striking symptoms are those 
of the nervous system resulting in stupor, pauseless 
respirations, and a toxic appearance. These are asso- 
ciated with diarrhea, vomiting and a rapid loss in weight. 
The history of preceding nutritional disturbances and in- 
fections are of great importance in diagnosis. 

Prognosis. This depends much on reaction to 
hunger diet, as very severe symptoms disappear often in 
twenty-four hours of starvation in the "food injuries. " 
If the same do not disappear in this time in this class 
of cases, in the absence of infection, the prognosis is bad. 
Infections add to severity. 

Treatment. 1. Removal of all food for twelve to 
twenty-four hours, with sufficient water administration. 

2. In severe types, subcutaneous salt infusions twice 
daily, 100 to 200 mils. Ringer's solution may be used to 
advantage for this purpose. 

Gm. or mil 

NaCl 7.5 

KC1 0.1 

CaCl 0.2 

Water 1000.0 

The water used in making this solution should be re- 
distilled shortly before using. 

If the infant presents evidence of acidosis, sodium bi- 
carbonate and dextrose may be added to the Ringer's 



STAGE OF ALIMENTARY INTOXICATION, 235 

solution, and administered intravenously in young infants 
through the longitudinal sinus, and in older infants into 
the anterior jugular or median basilic vein. 

About 4 Gm. (60 gr.) of sodium bicarbonate and 
6 Gm. (90 gr.) of dextrose may be added to 120 
mils (4 ounces) of saline solution, and repeated in four 
to six hours if indicated. 

It should be remembered that intravenous administra- 
tion of large amounts of sodium bicarbonate may result 
in collapse. 

Pure dextrose is essential (Kahlbaum's is a good 
product). If dextrose appears in the urine, the adminis- 
tration should be stopped. 

3. Salines per rectum, best administered by the drop 
method. Thirty drops per minute for four hours is 450 
mils. One-half strength of Ringer's solution may be 
used. Sodium bicarbonate, 5.0 Gm. (75 gr.) may be 
added to every 500 mils of the solution (1 per cent.). 

4. One lavage, if food has been given shortly before, 
or if vomiting is severe. 

5. Avoid all laxatives, as the bowels empty them- 
selves, and any further purgation increases the loss of 
salts and water, and increases the tendency to develop- 
ment of an acidosis. 

6. Analeptics. Give a mustard bath in case of col- 
lapse. Reddening of the skin is a good sign. 

7. Antipyretics. Use tepid packs, and leave the in- 
fant undressed. Ice-cap to head is useful, but should not 
be applied directly to the head, because of the thinness of 
the skull in young infants. 

8. Stimulants. In collapse, warm packs or baths are 
indicated. Caffein sodium benzoate, 0.006 Gm. to 0.030 
Gm. (0.1 to 0.5 gr.) four or five times daily; camphor- 



236 INFANT FEEDING. 

ated oil in 1-mil doses every two hours hypodermically 
if indicated; epinephrin solution, 0.5 mil (1 to 1000), sub- 
cutaneously or intravenously. 

9. Sedatives for convulsions. Sodium bromide 0.2 
Gm. to 0.3 Gm. (3 to 5 gr.) repeated in three to four 
hours; veronal, 0.05 Gm. Chloral hydrate is best 
avoided. 

10. Opium may be indicated when the diarrhea re- 
mains uncontrolled by other methods. Paregoric in 
suitable doses per mouth, or the tincture per rectum may 
be used with care. 

11. An electric fan is a most valuable addition to our 
therapeutic measures in summer. 

12. Lumbar puncture may be indicated in the presence 
of increased intracranial pressure, and for diagnostic 
purposes. 

13. Diet. Hunger diet should be employed rarely 
longer than twenty-four hours. Occasional administra- 
tion of dilute saline solutions (NaCl 5, NaHC0 3 5, water 
1000) per mouth, or thin gruels may soon be used with 
care to supplement an occasional feeding. When infant 
is stuporous, water should be administered by gavage at 
regular intervals of about three to four hours. 

In cases of food intoxication, twenty-four hours on a 
hunger diet causes striking changes. The child looks 
bright, smiles, and to all appearances looks convalescing, 
notwithstanding a usual loss of weight. The stools also 
become less frequent, and although small and containing 
mucus (hunger stools), they cause less irritation of the 
buttocks and little loss of water. The improvement is no 
less striking than that seen in the crisis of pneumonia. 

Human Milk. Human milk is by all means the best 
food. Feed often, and in small amounts, ten times daily, 



STAGE OF ALIMENTARY INTOXICATION. 237 

5 mils from bottle or spoon. The infant may also be 
placed directly at breast for one- or two- minute periods 
in less severe cases. Increase when the temperature, etc., 
do not react to food, and then not more than 50 to 100 
mils daily increase at first. After several days, if the in- 
fant shows no evidence of relapse, it is again place'd un- 
restrictedly on the breast. If this is done too soon, re- 
intoxication occurs. A too prolonged starvation adds 
the danger of inanition. 

A sustaining diet should be reached in eight to ten days 
(32 calories per pound), after which the child can be put 
on the breast five times daily. Weigh infant before and 
after feeding, if placed at the breast. If the elevation of 
temperature returns, except in the presence of infection, 
cut down the food. The gain in weight is very slow in 
the stage of repair on human milk, due to the low pro- 
tein and salt content. 

Cow's Milk. For the first few days after the hunger 
day, a food low in fat and sugar should be fed, because 
of the lowered tolerance. One-half skim milk or butter- 
milk, boiled or citrated without sugar, will answer, but 
should be fed in small quantities, 10 times 5 mils daily, 
then 10 times 10 mils. On this low diet weight loss and 
temperature will usually stop. There is, however, again 
great danger from underfeeding too long, so that these 
infants offer every indication for our best judgment. At 
all times plenty of indifferent fluids should be adminis- 
tered between feedings. After ten to fourteen days, 32 
calories per pound may be fed. Less rapid increase than 
in human milk feeding should be the rule. Older infants 
can be given gruels in their milk. Recurrence of dyspep- 
sia is an indication for return to indifferent foods. With 
a second recurrence breast milk is absolutely indicated. 



238 



INFANT FEEDING. 



Return to carbohydrates should be made with great care, 
adding 1 per cent, to the food mixture, and increasing to 
5 per cent, with continued improvements. The maltose- 
dextrin compounds are best for this purpose. 

Albumin milk is indicated in this condition, and the 
following is a good working rule for its use in these 
cases : First day, tea. Second day, 10 times 5 mils albu- 
min milk with tea ad libitum. Increase 50 mils daily 
until stools are good ; then further increase 100 mils daily 
until 180 to 200 mils are given for each kilogram of body 
weight (3 ounces per pound). After the stools are firm, 
add sugar to the food, and increase gradually to 4 per 
cent. Maltose-dextrin compounds are best. In intoxi- 
cation we have obtained better results by at first feeding 
albumin milk without sugar addition, but containing 1 
per cent, of flour (flour ball). After six to eight weeks 
an ordinary milk mixture may be fed. Feedings can 
now be reduced to five or six daily. Never feed over 
1000 mils a day of albumin milk. Before this amount 
can be digested we have usually reached the point where 
sugar can be added to meet the caloric needs of the 
infant. 



CHAPTER VII. 

MIXED FORMS OF NUTRITIONAL 
DISTURBANCES. 

Disturbed metabolic balance is frequently associated 
with dyspeptic symptoms. Again, these may show signs 
of intoxication. Decomposition is the form most subject 
to complication. 

Treatment. Disturbed metabolic balance with dyspep- 
tic symptoms is to be treated as dyspepsia, by reducing 
the diet. In dyspeptics with signs of intoxication employ 
hunger diet, etc. 

Decomposition complicated by intoxication is the 
severest combination, but can be recognized, if careful 
consideration is given to the history and to the infant's 
general condition. The greatest danger lies in the fact 
that in the former we must nourish, in the latter starve. 
With only a short hunger period (six hours) either 
human or albumin milk should be given in small quanti- 
ties, 10 times 5 mils, and increased by 50 mils daily under 
control of the clinical symptoms. After 8 to 10 days of 
the above, the infant can usually be put to the breast five 
times daily. The weight may remain stationary, and one 
must judge by the stools and general condition as to the 
addition of further foods. With albumin milk, after 
three to four days, the weight becomes stationary, and 
the stools of a fat-soap character; then gradually some 
malt-sugar may be added. 

In nutritional disturbances associated with an infection 
an early diagnosis is most important, otherwise there is 
the danger of carrying the underfeeding to the point of 
lowering the resistance of the child beyond repair. 

(239) 



CHAPTER VIII. 

NUTRITIONAL DISTURBANCES DUE TO 
INSUFFICIENT FOOD. 

This group of cases may be divided into two classes: 
(1) Quantitative inanition, (2) qualitative inanition. 

1. Quantitative Inanition. The cases of this class 
include those infants receiving a diet containing a proper 
proportion of the necessary food ingredients, but of in- 
sufficient caloric value. (Too little of a proper food.) 
These must again be divided into two groups : 

(a) Normal infants quantitatively underfed. 

In breast-fed infants this group is more common than 
in artificially fed. And while in the artificially fed such 
cases are occasionally seen, this is a far less frequent 
condition than overfeeding. Because in the normal in- 
fant hunger is manifested by crying, restlessness, loss 
of weight and associated constipation, which fortunately 
in most instances leads to a proper interpretation, result- 
ing in increase of the diet. 

(6) Infants suffering from nutritional disturbances, 
quantitatively underfed. 

These cases are the ones which so frequently suffer 
from quantitative inanition, due to the fact that the fever, 
vomiting, and diarrhea offer every indication for a re- 
duction in diet, or a starvation diet. While this leads to 
an improvement in the general symptoms, the remaining 
hunger stool, because of its greenish-brown color and 
excess of mucus, is not uncommonly interpreted as a 
diarrheal stool, leading to prolonged starvation, and not 
infrequently repeated catharsis. 
(240) 



DISTURBANCES DUE TO INSUFFICIENT FOOD. 241 

The similarity of the grave hunger conditions follow- 
ing repeated starvation to decomposition is very striking. 
This is easy to understand, because the symptoms of de- 
composition are after all due to a condition of inanition 
caused by deficient absorption of food, and by loss of the 
body substance. In the beginning, and for a longer time 
thereafter, the inanition differs from decomposition in 
the reaction to the increase of the food, which in simple 
inanition is followed by gain in weight, in decomposition 
frequently by loss of weight. Finally, however, even in 
the child suffering from simple inanition the weakening 
of the organism reaches the stage in which there is a 
decrease of tolerance to food. 

Treatment. Prophylaxis. Repeated hunger days 
and long-continued underfeeding should be instituted 
only upon definite indications, the sudden decrease in the 
food leading regularly to weight loss and lowered food 
tolerance. 

An initial cathartic is frequently indicated, while re- 
peated catharsis is harmful. 

The diet should be as rapidly increased as the infant's 
condition will tolerate. It should be carefully selected to 
meet the requirements of the individual infant. 

While in mild cases a properly selected diet leads to 
rapid recovery and gain in weight, in the severe cases 
bordering on decomposition, we not infrequently see a 
paradoxical reaction to food, necessitating feeding as 
described under the chapter on Decomposition. 

In every case the infant's tolerance to food should be 
carefully studied, and increases made only as tolerance 
permits. 

Hunger stools are rapidly replaced by those of normal 
consistency in the presence of a proper diet. 

16 



242 INFANT FEEDING. 

2. Qualitative Inanition. As qualitative inanition 
are designated those forms of nutritional disturbances 
which are due to the lack or insufficiency of one or more 
indispensable food substances or constituents of the 
food. The qualitative inanition is very frequently asso- 
ciated with quantitative inanition. 

Flour Injury. 

From among these conditions of inanition the most 
frequent in the infant is the flour injury (Mehlnahrscha- 
den — Czerny and Keller). 

Etiology. The condition follows feeding with a diet 
composed largely of cereals or cereal waters, as is fre- 
quently seen when these are used to replace milk mix- 
tures which have been poorly taken (dyspepsia, etc.). 
It is therefore due to continued feeding of flour gruels, 
either without milk or a diet too low in milk content. 
Whether simple flour or baby foods, dextrinized or not 
are used, the result is the same. Although the flour in 
its digestion is changed to sugar, the effects are not tho&e 
of excessive sugar diet (acute), but only leads to acute 
symptoms after the organism has been generally im- 
paired by the long use of the one-sided diet. 

Pathogenesis and Metabolism. The disturbance of 
the organism which develops on one-sided flour feeding 
is to be regarded as qualitative inanition, being due to 
the lack of important tissue-building substances (fat, 
proteins, salts), and the resulting improper formation of 
the body tissues. 

Steinitz and AYeigert found in animals that a flour diet 
led to an abnormal chemical composition of the organ- 
ism. The body became richer in water and £at than nor- 
mal, and this excess of water reduces the natural im- 



DISTURBANCES DUE TO INSUFFICIENT FOOD. 243 

munity. The oedema indicates a disturbance in the salt 
balance between the tissues and body fluids. 

In many cases, also, the caloric intake may be insuffi- 
cient, so that quantitative inanition complicates the pic- 
ture. The accumulation of large quantities of water 
which occurs when large quantities of flour are fed in 
presence of salts results in fluctuations in weight. 

Rapidity of development depends on the following 
factors : 

1. Age. The younger the child, the quicker the effects. 

2. The more the flour outweighs the other ingredients 
of the diet. 

Symptoms. They may assume any form of nutri- 
tional disturbances. In many cases apparent symptoms 
of disease are lacking for a long time in spite of the 
improper diet. The infant may even apparently thrive 
well, since (due to the great water-binding property of 
carbohydrates) considerable gains in weight may occur. 
The appearance of the child is good, and fat cushion 
abundant. Even at this time, however, frequently some 
anomalies are observed : the musculature may be slightly 
hypertonic, the appearance may be pasty, suggesting a 
water-soaked sponge. Not infrequently by careful exam- 
ination nervous irritability (latent tetany) may be de- 
tected. This is followed by development of grave symp- 
toms of typical flour injury, which may assume variable 
appearance, according to whether the flour is given alone 
or combined with some other food. 

Flour has the property of causing the body to take on 
weight by water absorption. This is especially true if 
the infant was previously healthy, and may be mislead- 
ing. In infants suffering from nutritional disturbances 
the picture develops more rapidly, especially upon in- 



244 INFANT FEEDING. 

auguration of repeated starvation diet. Finally, how- 
ever, both these groups of infants present the picture of 
an inanition — that is, the atrophic stadium, which cannot 
be distinguished from a decomposition clinically. They 
are subject to rapid weight and water losses, showing the 
loose binding of the water in the tissues. 

(Edema may complicate the picture, especially where 
the flour is given in a salt-rich diet as bouillon, milk, etc., 
and the oedema may resemble that of a nephritic patient 
(urine is usually negative). 

The natural immunity in these hydremic conditions is 
greatly reduced, and the children are subject to furun- 
culosis, otitis, and infections of the respiratory and diges- 
tive tracts, all of which give a bad prognosis. 

Hypertonia is very common, with a characteristic mus- 
cular rigidity, resulting in stiffening of extremities, opis- 
thotonos, etc., and it is often difficult to differentiate 
them from cases of spastic cerebral paralysis and chronic 
tetany, from which latter these infants often suffer. 
The history of nerve irritability must be used as a point 
of differentiation. 

Hypertonic form has also been described, the chief 
symptom of which is the rigidity of the muscles. This 
hypertonicity may occasionally assume such proportions 
that the limbs and the entire body may become rigid. 
But this condition is not exclusively caused by flour in- 
jury, but may be seen also in other nutritional dis- 
turbances. 

Stools. Often the stools are good for a long time, 
but sooner or later in all cases acute intestinal symptoms 
develop. More characteristic, after continued feeding on 
a one-sided flour diet are soft, mushy, loose stools, which 
are frequent, and vary in color from brown to yellow. A 



DISTURBANCES DUE TO INSUFFICIENT FOOD. 245 

further characteristic is a tendency to fermentation, with 
the formation of acids and gas, which tend to irritate the 
buttocks. The small, dark-brown stools, composed 
mainly of mucus (hunger stools), are not infrequently 
seen, and are of especial significance, because they are 
often misinterpreted as dyspeptic stools. 

Diagnosis. The feeding history is of the utmost 
importance. Hypertonia and oedema should lead to sus- 
picion. Presence of excessive fermentation or of "hun- 
ger stool." 

Prognosis. The younger the infant and the longer 
the unsuitable diet has been continued, the worse is the 
prognosis. The high mortality in this condition is due 
not so much to the nutritional disturbance itself, but 
more so to unavoidably complicating infections. Tetanies 
and convulsions due to them are also grave complications. 

Prophylaxis. The development of a primary flour 
injury is prevented by ordering proper diet. In using the 
flour diet for therapeutic purposes in the treatment of 
dyspepsia, especially when repeated starvation is in- 
augurated, the danger of development of the flour injury 
must be kept in mind, and the one-sided diet must not 
be continued longer than several days. 

Treatment. 1. Human Milk. In young infants and 
also in all severe cases, feeding with human milk offers 
the best hope for the cure of the condition. It is abso- 
lutely indicated (1) before the third month, (2) in evi- 
dence of decomposition. 

Begin with 200 to 300 mils daily, as in decomposition, 
and continue, even with weight loss and development of 
dyspeptic symptoms. Increase the amount steadily. 
Even with human milk the course will be slow, if the 
condition is well advanced. 



246 INFANT FEEDING. 

2. Artificial Feeding. One-half to two-thirds skim 
or whole milk plus water in feedings of 10 times 10 mils 
with water or tea ad libitum. Continue, even with weight 
loss, which is the rule, unless the stools are dyspeptic. Tt 
may often be of advantage to make the loss slower by 
addition of some flour or maltose-dextrin preparations to 
the milk mixture. Albumin milk and buttermilk mix- 
tures are often taken to better advantage than whole 
milk mixtures. If they fail, human milk must be given. 

If stools retain fat-soap character after 10 to 14 days, 
the diet may be more rapidly increased. 

Course is often interrupted by weight drops and in- 
fections. 

In very severe cases in which symptoms of decomposi- 
tion are present, same treatment as in decomposition 
should be instituted. 



CHAPTER IX. 

INFECTION AND NUTRITION. 

The intimate relation between infection and nutrition 
may be made clear by considering the subject under three 
headings : 

1. The susceptibility to infections as influenced by 
previous diet and the state of nutrition. 

2. The course of infections as affected by diet and the 
state of nutrition. 

3. The influence of infection upon nutritional proc- 
esses. 

(a) Parenteral infections. 

(b) Enteral infections. 

1. Susceptibility Influenced by Nutrition. 

The previous diet and the state of nutrition being the 
same, there are marked individual differences in the sus- 
ceptibility to infection. Among the breast-fed infants 
there are on one hand infants who remain free from any 
infection, even under very unfavorable external condi- 
tions, while on the other hand there are breast-fed infants 
who under favorable conditions often contract an infec- 
tion. This points to congenital differences based x>n the 
difference in the constitution of the individual. As a 
rule, the lowering of immunity is not the only sign of 
inferior constitution in these infants, but they show a 
number of other symptoms of a constitutional anomaly, 
such as exudative and neuropathic diathesis. In this 
group of infants the susceptibility to infection becomes 
even more striking when they are put on artificial feeding, 

(247) 



248 INFANT FEEDING. 

and especially when the diet is improper. In infants 
with constitutional anomalies one is justified in thinking 
of an abnormal composition of the tissues and of the 
body fluids, both the latter factors in themselves leading 
to a lowering of immunity. 

The natural immunity of the healthy breast-fed infant 
affords the best example of the importance of the diet 
in the establishment of resistance to infection. 

In the artificially fed infants the increased susceptibil- 
ity to infection is usually based on nutritional disturb- 
ances, which, however, may be so slight as to escape 
recognition. However, when a careful study is made 
of the feeding history the cause can usually be demon- 
strated in a poorly balanced diet, more commonly one 
excessive in carbohydrates and fats, which result in an 
abnormal composition of the tissues (see Nutritional 
Disturbances). Those modes of feeding which cause 
normal tissue chemistry diminish susceptibility, while 
every form of feeding which unfavorably influences 
metabolism increases susceptibility to infection. 

In the artificially fed infants these facts offer valuable 
therapeutic suggestions, and should lead one to avoid 
overfeeding as a whole as well as of the individual con- 
stituents of the diet, and the early administration of the 
mixed diet. 

The susceptibility to infection is increased by every 
nutritional disturbance. This applies to the simple and 
seemingly harmless digestive disturbances, as well as to 
the more severe forms (decomposition, intoxication). 

2. Course of Infections Influenced by Nutrition. 

The course of the infection is essentially influenced by 
constitution, age, hygienic conditions, mode of feeding, 



INFECTION AND NUTRITION. 249 

and the state of nutrition. The premature and the very 
young react poorly to infections. Gastro-intestinal, pul- 
monary and septic infections of the newborn have usu- 
ally an unfavorable course, especially in the artificially 
fed infants. Infants suffering from constitutional anom- 
alies are less likely to react favorably than normal, 
healthy infants. In all infants suffering from exudative 
or neuropathic diathesis even slight infections should be 
given serious consideration. 

Nutritional disturbances have a direct influence on the 
prognosis of all forms of infections. This is more espe- 
cially true of the infections of the respiratory passages, 
in which a simple rhinitis or pharyngitis may readily be 
complicated by pneumonia and severe gastro-intestinal 
complications, but also true of the simple skin infections, 
which may rapidly take a serious course resulting in 
sepsis. 

The institution of a proper diet is of primary impor- 
tance in all cases of infections. 

Feeding with human milk is the treatment of choice. 
If this is not obtainable, and it is necessary to feed arti- 
ficial food mixtures, they must of necessity be well bal- 
anced, and excesses of carbohydrates are to be avoided. 
Whenever possible, a mixed diet should be instituted. 

3. Infection Influencing Nutrition. 

Infection may produce any form of nutritional dis- 
turbance, from the slightest forms to the most severe 
forms of decomposition and intoxication. One may al- 
most say that, for the production of nutritional disturb- 
ances, infections are to be ranked as of equal importance 
with dietetic errors. 



250 



INFANT FEEDING. 



Although the course of alimentary nutritional disturb- 
ances is very similar to that of nutritional disturbances 
due to infection, still there are important differences that 
must be kept constantly in mind in order to avoid fail- 
ures in the treatment. The following table briefly sum- 
marizes the most important differences between the two 
forms of nutritional disturbances : 



Nutritional Disturbances due to 
Alimentation. 

History of dietetic errors, espe- 
cially high sugar diet. 



Disintoxication of toxic states 
(fever, nervous symptoms, 
etc.) by withdrawal of food. 

Improvement in general con- 
dition, and especially of diar- 
rhea, on correction of the 
diet, especially by reduction 
of whey and sugar com- 
ponent part. 

Progressive narrowing of food 
tolerance in untreated cases. 



Nutritional Disturbances due to 
Infection. 

Acute disturbances not so 

much dependent on the 

nature of the diet. 

Toxic states continue or even 
become worse in spite of 
withdrawal of food. 

Persistence of diarrhea after 
similar change of diet, at 
least in a number of cases. 



Spontaneous increase of toler- 
ance without special dietetic 
treatment after the infection 
passes over (in majority of 
cases, not always). 



(A) Parenteral Infections. 

Etiology. It has already been pointed out with 
what great frequency infants and children suffering from 
nutritional disturbances are subject to secondary infec- 
tion. The most frequent of these are those of the skin, 
respiratory, gastro-intestinal, and genito-urinary tracts, 
ears and general septic infections. 



INFECTION AND NUTRITION. 251 

In contradistinction to this, infections, such as "colds," 
tonsillitis, pneumonia, otitis, cystitis, pyelitis, which are 
accompanied by lowered food tolerance, very frequently 
result in secondary nutritional disturbances. They are 
likely to run a more severe course than the primary 
nutritional disturbances. 

The common occurrence of the "summer diarrheas" 
leads us to search for a relationship between heat and the 
nutritional disturbances as seen in summer. This rela- 
tionship has already been discussed under the chapter on 
Intoxication. However, it may be well to briefly enumer- 
ate the factors which are important in the causation of 
these nutritional disturbances. High temperatures cause 
systemic depression, and directly influence all of the body 
functions. Less food is required in hot weather, and 
therefore the previous diet may be considered excessive 
in many instances. Bacterial action on the milk, and the 
subsequent production of toxic bodies, is a factor of pri- 
mary importance. An excessive retention of heat by 
overdressing during the summer months has been proven 
to be a contributing factor by McClure and Sauer.* 

A study of the cases of diarrheas in the wards of 
Sarah Morris Hospital by Gerstley and Day during the 
course of two summers showed that most of our intes- 
tinal cases were secondary to parenteral infections, and 
not primary intestinal infections, as described by Ken- 
dall and Day in their investigations of the Boston epi- 
demics. This could in greater part at least be accounted 
for by the fact that all of the milk fed to our infants was 
either pasteurized or boiled, while in the eastern cities 
considerable raw milk was fed. 



* Scauer, Am. Jour. Dis. Child., 1915, ix, 490. 



252 INFANT FEEDING. 

Symptoms. By careful clinical observation and ex- 
perimental investigation L. F. Meyer has shown that in- 
fection may produce the following changes : 

1. Diminution in the gain in weight without any acute 
symptoms on the part of the gastro-intestinal canal dur- 
ing or after the infection. 

2. Loss of weight and changes in the stools cor- 
responding to the acute nutritional disturbances. 

(a) Acute disturbances of the nature of dyspepsia 

beginning with the infection and disappear- 
ing after the infection has been overcome. 

(b) Acute disturbances which begin with the infec- 

tion, but remain even after the infection is 
overcome, under certain conditions for weeks 
(chronic dyspepsia). 

(c) Grave nutritional disturbances beginning with 

the infection, but soon becoming the most 
prominent factor in the clinical picture, with 
or without toxic symtoms (intoxication, de- 
composition). 

Diagnosis. Alimentary intoxication is usually easily 
recognized by the nervous symptoms, toxic expression, 
pauseless respiration, and marked drops in the weight 
curve. In intoxication, temporary complete withdrawal 
of food in the absence of severe infection results in dis- 
intoxication. This is known as therapeutic dietetic test. 
In parenteral infections this is not the case, and starva- 
tion only leads to further reduction of resisting power, 
and therefore should not be long continued. 

It is necessary to avoid the mistake of overestimating 
the intestinal condition for which in many cases the 
physician is called, and thereby failure to recognize the 



INFECTION AND NUTRITION. 



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254 INFANT FEEDING. 

underlying infection, such as "cold," bronchitis, pneu- 
monia, pyelitis, etc., as a fundamental factor. 

Treatment. For treatment practically the most im- 
portant characteristic of nutritional disturbances due to 
infection is the spontaneous rise of food tolerance after 
the cure of the infection. 

The primary infection calls for foremost considera- 
tion, and its treatment must necessarily vary according 
to its nature. The intestinal condition, on the other hand, 
if mild in nature, frequently calls for little treatment in 
these infants, more especially because in the presence of 
fever there is a tendency to reduce the intake of food, 
which in itself is sufficient to correct the intestinal dis- 
turbance. Further, with the improvement of the infec- 
tion the appetite returns, and the infant will demand in- 
creased food. 

Where it is possible to keep up the baby's nutrition by 
the proper administration of food during the course of an 
infection, such children may be subject to little or no 
weight loss. In more serious cases the food must be re- 
duced both qualitatively and quantitatively, more espe- 
cially the sugars and the fats. However, in order to 
avoid catastrophes, long-continued underfeeding or star- 
vation must of necessity be avoided, since this treatment, 
causing insufficient nutrition of the body-cells, would de- 
crease the resistance of the infant. 

The safest plan when human milk is not available is to 
administer in place of carhohydrate- and whey-rich mix- 
tures, which, as has often been pointed out, easily lead to 
acute digestive dusturbances, mixtures high in proteins 
and low in sugar and whey. Albumin milk, and skim and 
buttermilk mixtures, with small amount of sugar are best 
used. In grave nutritional disturbances, with sudden 



INFECTION AND. NUTRITION. 255 

losses of weight and toxic symptoms, complete with- 
drawal of food cannot be avoided. 

In young and weak infants, as previously stated, breast 
milk may be imperative. In older infants, and those less 
severely infected, albumin milk, with 2 or 3 per cent, of 
sugar addition, or buttermilk and skim milk mixtures are 
frequently well taken. In all cases inanition must be 
avoided by keeping the child on a sustaining diet of 70 
calories per kilogram, or an amount above this. 

The type of infants who have been improperly fed, 
more especially those who have been raised on con- 
densed milk or other foods containing a minimum of 
fat and protein, but an excess of carbohydrates, offer 
greater difficulties, because they possess a limited im- 
munity to all forms of infection, beside reacting poorly 
to changes in their diet during illness. They also react 
very poorly to starvation, rapidly passing into a state of 
decomposition. The treatment in these cases should fol- 
low that outlined for milder forms of decomposition. 

To repeat, under all circumstances food should be re- 
stricted as little as possible. 

The two most important symptoms calling for treat- 
ment in the course of parenteral infections are ( 1 ) vomit- 
ing and (2) refusal of food. 

If temporary reduction in food does not relieve vomit- 
ing, it may be necessary to resort to gastric lavage which 
is best performed with 1 per cent, sodium bicarbonate 
solution, allowing 2 or 3 ounces of the solution to re- 
main in the stomach, with the administration of slightly 
sweetened tea or cereal waters ad libitum, as retained. 
Prolonged starvation must be avoided. 

We have found chymogen milk fed in small quantities 
at two- to three- hour intervals especially suitable for 



256 INFANT FEEDING. 

these cases. This is probably due to the fact that the 
casein is precipitated in a flocculent form. 

Refusal of food which is commonly experienced in 
these infants calls for catheter feeding (see chapter on 
Premature Infants). 

(B) Enteral Infections. 

Etiology. Besides the alimentary nutritional dis- 
turbances proper, there are in childhood, and especially 
in infancy, numerous diseases that have to be regarded 
as true infections of the digestive canal, due to invasion 
of pathogenic bacteria, or increased and changed activity 
of the bacteria normally present. In many cases infective 
material is introduced by food, and especially by the 
milk, in which the micro-organisms are present, being de- 
rived from the diseased cattle that furnishes the milk 
(Streptococcus from inflamed udders, Bacillus coli from 
feces) or bacteria pathogenic for the human may find 
their way into the milk in transportation from the place 
of production to the place of consumption. Besides this, 
water or contaminated foods other than milk may be the 
medium through which infection takes place. 

There are numerous cases of transmission by contact. 
These are most commonly seen in the epidemic appear- 
ance of gastro-enteritis in institutions for small children 
and infants. A small, but typical epidemic is reported 
by Smillie* who has observed it during his study of epi- 
demiology of bacillary dysentery. Four babies developed 
bacillary dysentery in the wards of the hospital, each of 
them having been admitted with quite a different diag- 
nosis, and their stools having been negative on admis- 



* Smillie, Am. Jour. Dis. Child., 1917, xiii, 337. 



INFECTION AND NUTRITION. 257 

sion. Each developed the disease seven to ten days after 
admission, and in no instance did the infant come from 
an infected home or neighborhood. 

The environment of the infant, and especially lack of 
proper cleanliness generally, and in preparation of food 
especially, are very important factors, which make the 
enteral infection possible. 

Parenteral infections are often followed by enteral in- 
fections, and this is especially true of infections of the 
respiratory tract which often lead to enteral infections 
producing what has been called "bronchoenterocatarrh." 

The most important clinical condition among the en- 
teral infections is inflammation of the intestinal mucosa 
(enteritis), brought about by a variety of bacteria, and 
accompanied by slimy, purulent, and bloody evacuations 
and tenesmus. The causative bacteria may be Strepto- 
cocci, Bacillus typhosus, B. paratyphosus, B. coli, B. dys- 
enterise, B. pyocyaneus, B. aerogenes capsulatus (gas 
bacillus), and B. lactis aerogenes. 

Kendall and Day, making a careful study of the epi- 
demics of summer diarrhea in Boston, found that during 
the year 1910 the epidemic was mainly due to dysentery 
bacillus, fully 75 per cent, of 52 cases being due to these 
organisms. Streptococci were also present in about 60 
per cent, of the dysentery cases, probably as secondary or 
terminal invaders. The summer of 1911 was noteworthy 
as a "streptococcus" year; 54 per cent, of 146 cases 
studied harbored large numbers of these organisms. The 
year of 1912 was a "gas bacillus" year, these organisms 
appearing in unusually large numbers in 39 per cent, of 
135 cases examined. Each of the above types was found 
each year, but the striking feature is the shifting of the 
dominant organism from year to year. Kendall con- 

17 



258 INFANT FEEDING. 

eludes that, bacteriologically considered, these cases are 
of varied etiology, caused by organisms of very unlike 
characteristics. 

In contrast to this, Gerstley and Day studied the sum- 
mer diarrheas at the Sarah Morris Hospital for Children 
(Chicago) during the course of two summers, and found 
that most of them were secondary to parenteral infections 
(see p. 249). Day worked both in Boston and Chicago 
cases, and therefore the error could not have been one 
of technic. The. difference was probably due to use of 
boiled milk in Chicago, and unboiled milk in the East. 

Pathology. To the invasion of pathogenic bacteria 
the digestive canal reacts by inflammation of the intes- 
tines (enteritis). The large intestine is always more 
affected, while in the small intestine the pathological 
process, as a rule, is limited to its lower portion. How- 
ever, in cases secondary to infections of the nose and 
throat, even the gastric mucosa may be involved. Mes- 
enteric lymph-glands are swollen. In some cases the 
bacteria invade the deeper organs also, and may be cul- 
tivated from the spleen and the gall-bladder. Liver and 
kidneys show degenerative changes in severe cases, 
probably due to the action of toxins. Occasionally 
other organs may secondarily become affected (otitis, 
pneumonia) . 

The inflammation of the intestines may reach any de- 
gree of severity, and is dependent to some extent at least 
upon the causative organism, being, as a rule, most 
marked in cases in which dysentery, typhoid, and strep- 
tococcic organisms are excitants of the pathological 
process. 

It may be a hyperaemia and swelling associated with 
exudation of excessive amount of mucus and occasion- 



INFECTION AND NUTRITION. 259 

ally of blood, producing a picture of catarrhal gastro- 
enteritis marked by mucus, mucopurulent, and occasion- 
ally also slightly bloody diarrheal stools. These cases 
are caused by a variety of bacteria, and they are often 
secondary to infections of the respiratory tract, the same 
micro-organisms being causative in both instances. We 
have frequently seen such a clinical picture associated 
with severe vomiting, and a secondary acidosis following 
in the course of a streptococcus sore throat. 

Intense swelling of Peyer's patches in the small intes- 
tine is seen in typhoid infection. Sloughing and ulcer 
formation is far less frequent than in the adults. 

In paratyphoid infections, while infiltration of Peyer's 
patches and solitary follicles are usually present, deep 
ulceration is lacking, as a rule. 

In infection with dysentery bacilli, the large intestine is 
especially affected, being the seat of sero-hemorrhagic 
and hemorrhagico-purulent inflammation, with marked 
tendency to formation of ulcers throughout a large part 
of the large intestine, and less frequently the lower ileum. 

Again, we may see marked intestinal pathology, as 
evidenced by deep-seated ulcerations and infiltrations of 
mucosa and secondary inflammation of the submucous 
and muscular layer of the intestinal wall, which condition 
is usually spoken of as ulcerative follicular colitis, and 
this may be complicated by formation of a pseudomem- 
brane in various areas throughout the large intestine, 
which condition has been described as a membranous 
colitis. In many of these cases it is difficult to determine 
the exact bacteriological factor, because of the presence 
of secondary organisms. Most of these cases are either 
subacute or seen as secondary involvement in infants who 
have suffered from repeated nutritional disturbances. 



260 INFANT FEEDING. 

On the whole, in those cases of inflammation of the 
intestinal tract due to bacterial infection and presenting 
serious pathological changes, the most marked changes 
are found in the lower three feet of the small intestine 
and in the large intestine. While there is very frequently 
a disparity between the severity of the clinical symp- 
toms and the pathological changes seen post-mortem in 
that not infrequently severe symptoms are associated 
with little pathology, on the other hand marked patho- 
logical changes are almost invariably associated with a 
severe clinical picture. 

Symptoms. The symptoms vary with the individ- 
ual excitant of the disease, and thus also to a certain ex- 
tent with the pathology, but, in general, the symptoms 
are so variable and with very few exceptions so little 
characteristic for the particular excitant that the etio- 
logical and pathological grouping of clinical pictures is 
impractical. It seems much better to differentiate the 
various forms from the clinical point of view. 

Diarrhea with slimy or purulent evacuations, often 
with blood, accompanied by abdominal pain, tenesmus 
and fever, are the most characteristic and the most con- 
stant symptoms of enteral infections. 

The onset and progress of enteral infections, as a rule, 
are sudden and rapid, and in this way they markedly dif- 
fer from alimentary nutritional disturbances in which 
prodromes consisting of milder symptoms are often pres- 
ent, and the progress is gradual. In enteral infections the 
stormy course may result in rapid production of a very 
severe picture of general prostration, and even an early 
fatal outcome. 

Diarrhea is so constant that these cases have been 
designated as "infectious diarrhea/' and yet it should be 



INFECTION AND NUTRITION. 261 

remembered that typhoid and paratyphoid infections in 
young individuals may be associated with any degree of 
constipation early in the disease. The stools are, as a 
rule, frequent, often one every hour, and there are also 
cases in which the bowels seem to move almost contin- 
uously. The number of stools varies also, according to 
the seat of the most severe inflammation, and they are 
more numerous when the large intestine is chiefly 
affected. 

Loss of weight, often sudden and marked, is always 
present, and is due to many evacuations, and also to ac- 
companying nutritional disturbance. 

Stools. The macroscopical appearance of individual 
stools varies not only with the etiological factor, but is 
also dependent to a great extent upon the reaction to 
food, and upon the intestinal pathology, and is therefore 
of little value in the etiological diagnosis of enteral in- 
fections. The size of the stools is indirectly propor- 
tional to their number. In the beginning they appear to 
be of normal composition, but sooner or later they are 
composed chiefly of mucus and blood, and occasionally 
pus may be seen, even by the unaided eye. Portions of 
the intestinal mucous membrane are seen in severe cases 
at the time of sloughing and ulceration. The odor of 
the stool varies with its composition, and thus with the 
progress of the disease. In the beginning the odor is that 
of the normal stool ; later stools, composed of mucus and 
blood, are almost odorless; and those containing large 
quantities of sloughs have often a putrefactive odor. 
The reaction of the stools varies also with their composi- 
tion, being mostly alkaline. , In exceptional cases the 
stools may not be considerably increased in number, and 
may contain neither mucus, nor blood, nor pus. 



262 INFANT FEEDING. 

Abdominal pain and tenesmus, due to irritation by the 
bacteria and their products, and also due to the abnormal 
intestinal contents, and to increased peristalsis, and some- 
times to distention, appear very early in the disease, often 
being the first symptoms. Although being severe usu- 
ally, they vary from a slight discomfort to excruciating 
pain, which keeps the child constantly awake, and, caus- 
ing exhaustion, adds to the severity of the case. Ab- 
dominal distention is intermittent, the abdomen being 
usually sunken. Abdominal tenderness is not frequent. 
Anorexia is almost always present, while vomiting is 
more commonly seen early. 

Fever is always present in enteral infections, and varies 
with the severity of the infection and the pathology. 
More often it is not extreme after the first exacerbations. 
It persists throughout the disease. 

Leucocytosis and oliguria are usually present. 

Enteral infections are always associated with nutri- 
tional disturbances, since the infection affects an organ 
chiefly concerned in nutritional processes. And nutri- 
tional disturbances, again, produce symptoms of their 
own. 

The course of enteral infections varies considerably, 
being dependent chiefly upon the nature of the organism 
and the stage of nutritional disturbance that develops, 
and also on the nature of complications. Some cases 
may be so mild as to resemble subacute dyspepsia, and 
only inability to influence the fever by the diet may point 
to their true nature. On the other hand, however, severe 
toxic conditions occur, being due either to sepsis or to a 
nutritional disturbance which develops secondarily to in- 
fection. The duration of the disease varies from a few 
days to several weeks. 



INFECTION AND NUTRITION. 263 

Complications. The great danger of the infections 
of the gastro-intestinal tract lies in their tendency to 
complications, at the head of which stand nephritis and 
pneumonia. Other complications are cysto-pyelitis and 
various pyodermatoses, and other pus infections and gen- 
eral pyaemia or septicaemia, which start either from the 
skin or from the diseased intestines. 

More important than this is the association of infec- 
tious diseases of the intestines with secondary nutritional 
disturbances. It is easy to understand that in severely 
diseased intestines the normal digestion of food is made 
especially difficult, and thus acid decomposition easily 
occurs, which in turn leads to dyspepsia, and in the wake 
of these even the alimentary decomposition and alimen- 
tary intoxication may be implanted upon the original dis- 
ease. The inanition caused by the flour injuries 
(Mehlnahrschaden) may in some cases reach disastrous 
gravity. There can be no doubt that the majority of the 
cases resulting in decomposition are not due to the in- 
fection alone, but also to the inanition and other forms 
of secondary nutritional disturbances, and it is probable 
that even a part of the severe ulcerative forms and vari- 
ous complications develop on the same foundation. The 
underfeeding alone gradually decreases the general power 
of resistance of the body; it weakens also the antibac- 
terial functions, and thus the local or general infection 
may spread unimpeded. 

Diagnosis. In making a diagnosis it is necessary to 
differentiate the enteral infections not only from (1) 
alimentary nutritional disturbances, but also from (2) 
nutritional disturbances caused by parenteral infections. 
(3) Diagnosis of the causative organism or group of 
organisms is also of great importance for the treatment. 



264 INFANT FEEDING. 

(4) Enteral infections are always complicated by nutri- 
tional disturbances, and it is of great importance to recog- 
nize the degree (dyspepsia, intoxication, decomposition) 
to which the infant is affected. 

In practice it is often difficult to differentiate clinically 
the gastro-intestinal infection from other forms of ali- 
mentary disturbances, because neither bloody and puru- 
lent stools nor the finding of pathogenic bacteria in the 
stools in itself is sufficient for the diagnosis of enteral 
infection, except possibly in the presence of typhoid, 
paratyphoid, and dysentery bacilli. 

An easily applicable method of differentiation is the 
test for the reaction to starvation and feeding. Fever 
continuing after withdrawal of food speaks for infec- 
tious etiology. Inability to influence the symptoms by 
diet is to be interpreted in the same sense. 

History is of considerable importance in making a dif- 
ferential diagnosis. The acute infectious diarrhea starts 
usually suddenly in a previously well baby, and pros- 
trates it at once, while the alimentary nutritional disturb- 
ance comes on gradually. In the latter we get a history 
of improper feeding, of previous nutritional disturbance, 
of parenteral infection. It is more gradually progressive. 

The differentiation between the enteral and the paren- 
teral infections is somewhat more difficult, and is to be 
made chiefly by exclusion of the parenteral infection by 
careful physical examination of the patient. The bloody, 
purulent stools are usually absent in the cases secondary 
to parenteral infection. 

The diagnosis of the causative organism is to be made 
by proper bacteriological examination and culture of the 
stools, and by agglutination reaction. Kendall states that 
frequently it is very difficult to determine the organism 



INFECTION AND NUTRITION. 265 

causing the disease, and therefore he has attempted to 
classify the causative organisms into two groups with a 
special reference to treatment.* He divides them into 
two large groups: (1) the various forms of dysentery- 
bacillus and all other organisms except the gas bacillus; 
(2) the gas bacillus and the allied organisms. 

While this classification of organisms for treatment 
theoretically offered great advantages, in our own clinical 
work we have not experienced the encouraging clinical 
results which might be expected, and have instituted a 
general course of treatment based more directly on the 
severity of the infection and the symptoms as presented 
by the cases at hand. 

Stool cultures should be made according to the method 
of Kendall for gas bacillus. This method is so simple 
that it may be performed even outside of a well equipped 
laboratory. Small portion of the stool is added to a test- 
tube of litmus milk. The test-tube is then heated on the 
water-bath, and left in the boiling water for three min- 
utes. By this procedure all the basteria in the stool that 
are not in stage of spores, are killed, and the basteria 
develop unrestrained from the spores subsequently. Gas 
bacillus, being sporogenous, survives the boiling. The 
test-tube is finally incubated at a body temperature for 
about twenty-four hours. In the presence of the gas 
bacillus a large part of the casein is dissolved, but the 
remaining casein is filled with holes, as if shot to pieces, 
and somewhat pinkish in color. The odor reminds one 
of rancid butter, and is due to formation of butyric acid. 
The true reaction may be easily differentiated from the 
pseudoreactions, in which some liquefaction of casein 



* Kendall and Smith : Bost. Med. and Surg. Jour., 1910, clxiii, 

578. 



266 INFANT FEEDING. 

also occurs, but in which the shotted appearance of the 
residual casein and the odor of butyric acid are absent. 

Differential studies for typhoid, paratyphoid, and dys- 
entery bacilli on endomedium and Russell's double sugar 
medium, and by further fermentation tests, are indicated 
in the presence of epidemic or severe endemic cases. 

While agglutination reactions are uncertain in very 
young infants, because of the slight tendency to the for- 
mation of agglutinins, in older infants and children it is 
of very considerable value, as demonstrated by the study 
of agglutinins by the author at Cook County and Sarah 
Morris Hospitals during the year 1914. In a series of 
30 cases studied in which agglutinations were made for 
typhoid, paratyphoid (alpha, beta, and Morgan), dysen- 
tery (Shiga and Flexner), and colon bacilli, the follow- 
ing organisms were demonstrated: typhoid, 2; paraty- 
phoid (Morgan), 1; dysentery, 2. All of these cases 
yielded the respective organisms in large numbers from 
their stool cultures. This method of examination is 
easily carried out in a well regulated laboratory, and is 
worthy of further consideration in the presence of an 
epidemic of enteritis or isolated cases of severe enteral 
infection. 

The stage of the nutritional disturbance is best diag- 
nosed by the reaction of the temperature and toxic symp- 
toms to complete withdrawal of food, and presence or 
absence of paradoxical reaction. (See also Dyspepsia, p. 
201 ; Decomposition, p. 214; Intoxication, p. 232.) Star- 
vation in the presence of infection must always be recog- 
nized as a dangerous procedure. 

Prognosis. The prognosis of enteritis is, in general 
favorable. Death is almost always due to complications 
with septic affections or nutritional disturbances. 



INFECTION AND NUTRITION. 267 

In infants and younger children the prognosis depends 
essentially upon the ability of the physician to apply the 
proper dietetic methods suitable for the particular case. 
If he succeeds — and this is at present possible in very 
many cases — to avoid graver secondary nutritional dis- 
turbances, then he will be able to save a surprisingly 
large percentage of cases; if he is unsuccessful in this 
direction, then his results will be unsatisfactory. 

Treatment. Prophylaxis. In etiology of enteral in- 
fections several facts based on bacteriological studies and 
clinical observations stand out so prominently that the 
methods of prophylaxis must be based upon them in 
order to be successful. 

1. In the great majority of cases the infection is intro- 
duced with the food. Whenever intestinal infection oc- 
curs in a breast-fed infant in a private home, the first 
thought should be that the infant was probably getting 
other food besides mother's milk, and only after exclu- 
sion of this probability the causes should be looked for 
in the environment of the infant, especially the cleanli- 
ness of the mother and the general hygiene of the home. 
In artificially fed infants the prophylaxis of enteral in- 
fections consists of obtaining pure and wholesome milk, 
keeping it clean, boiling when in doubt, and careful prep- 
aration of proper mixtures. 

2. In many cases the infection occurs by contact, espe- 
cially in institutions. Isolation of severe cases of intes- 
tinal infection is therefore essential, and isolation of all 
suspicious cases advisable, especially in institutions. 

3. The environment of the infant, and especially lack 
of proper cleanliness generally, and in preparation of 
foods especially, are very frequently predisposing and 
accessory factors. The methods instituted to counteract 



268 INFANT FEEDING. 

these influences must, of course, be adapted to the in- 
dividual case. 

4. Parenteral infections are often followed by enteral 
infections. Proper treatment of parenteral infection, 
special attention to the diet and general hygiene, are the 
keynote of prophylaxis in these cases, the possibility of 
secondary enteral infection being constantly kept in mind. 

5. Alimentary nutritional disturbances increase suscep- 
tibility to any form of infection, and especially to enteral 
infection, and the prophylaxis of secondary enteral in- 
fections coincides practically with the prevention and 
proper treatment of these nutritional disturbances. (See 
also "Susceptibility Influenced by Nutrition/' p. 245.) 

Initial. The object of the initial treatment is to de- 
crease as much as possible the number of bacteria present 
in the intestine, and the removal of irritating intestinal 
contents. Intestinal disinfection by drugs is impossible; 
and the cleansing of the intestines by the administration 
of large quantities of inert fluids, enemata, and possibly 
an initial laxative, is the best that can be done in this 
direction. 

Castor oil, which is usually taken plain without any 
difficulty by infants, in doses of 1 to 2 teaspoonfuls, is 
the best laxative for these cases, since it causes very 
little intestinal irritation. Only in cases where it is 
vomited, we should resort to magma magnesise {y 2 to 4 
teaspoonfuls), or to calomel, 0.06 gram (1 gr.), given 
in doses of 0.015 gram (J4 g r -) every half an hour until 
four doses are given. Calomel is administered with 
sodium bicarbonate. The calomel can be followed to 
advantage with 1 or 2 teaspoonfuls of magma magnesiae. 

An enema of physiological saline (1 teaspoonful of 
salt to 1 pint of water) is useful. 



INFECTION AND NUTRITION. 269 

All food should be stopped for from six to twelve 
hours. It is not desirable, as a rule, to withhold the food 
longer than this time. 

Water should be given freely during the starvation 
period, and in quantities that are at least equal to the 
past total intake of fluids. The water may be given 
either warm or cool, or in the form of weak tea. Sac- 
charin may be used to sweeten it, using 0.01 gram 
(% S r -) °f saccharin to 8 ounces of water, if desired. 
In presence of marked anorexia or refusal of fluid on the 
part of the infant, the water or tea must be ad- 
ministered by catheter. In persistent vomiting frequent 
resort to gastric lavage with 1 per cent, sodium bicar- 
bonate solution will relieve vomiting, and be followed by 
retention of fluids given by mouth. When the latter does 
not relieve the vomiting, physiological saline solution or 
Ringer's solution must be given either by rectum or 
subcutaneously. 

Local and Medicinal Treatment. Abdominal pain and 
tenesmus are aften so severe that they require a special 
treatment. Moist heat in the form of compresses, hot 
water bottles or electric pads should be given preference, 
and only in cases in which they do not afford relief 
recourse should be had to opium or morphine. Tincture 
of opium in doses of 3 to 5 drops may be given in 10 per 
cent, starch solution by the rectum, or 0.01 to 0.03 gram 
(% to y 2 gr.) of pulvis ipecacuanhse at opii (Dover's 
powder) (beware of vomiting), or 5 to 20 drops of 
tinctura opii camphorata (paregoric) by mouth. In some 
cases 1 or 2 doses of morphine may be preferable, since 
it decreases the peristalsis less markedly than opium ; the 
dangers of its administration to infants must be remem- 
bered, and the dosage must be minimal (0.0003 to 0.001 
gram— %oo to % gr.)- 



270 INFANT FEEDING. 

Stimulants are indicated in some cases of extreme ex- 
haustion, and in cases of sudden collapse. In the ab- 
sence of hyperexcitability of the nervous system, strych- 
nin is the most generally useful stimulant. It is given 
in doses of 0.00005 to 0.0003 gram (% oo to y 200 gr.). 
Caffein in the form of caffein sodium benzoate, or 
citrated caffein, are of value, and are given in doses of 
0.01 to 0.03 gram (% to y 2 gr.). Camphor 0.05 to 0.10 
gram (1 to 2 gr.) dissolve'd in sterile oil may be injected 
subcutaneously in emergency. 

Special symptoms and conditions arising during the 
course of the disease, as are high fever, excessive vomit- 
ing, symptoms of nervous excitation, or extreme depres- 
sion, are to be treated as detailed under Intoxication 
(p. 232). 

Injections of silver nitrate are of value in some cases 
where blood and pus persist in the stool even after the 
subsidence of acute symptoms, and especially in dysen- 
tery. Before an injection is given, the colon should be 
irrigated first with sterile water (not saline). One 
per cent, silver nitrate solution is then injected in a suit- 
able quantity. If it causes any pain or irritation, it 
should be washed out with saline solution. It should not 
be repeated more often than once a day, and if three 
injections do not result in marked improvement it is 
better to discontinue them. 

Dietetic Treatment. Hitman Milk. The ideal treat- 
ment for all cases of intestinal infections would most 
naturally be best accomplished by feeding with human 
milk, and whenever obtainable, more especially in 
the severe types, it is by all means the diet of choice. 
Feeding with human milk, especially in young infants, 
produces very good results, because it retards the 



INFECTION AND NUTRITION. 271 

complicating nutritional disturbance, and thus favors 
healing. 

Artificial Feeding. From the great number of food 
mixtures that have been advised for enteral infections, 
we may judge as to the lack of any specific action. It is 
probable that success may be obtained with any feeding 
which prevents the aggravation of nutritional disturb- 
ance, and favorably influences the nutritional disturb- 
ance which may exist. Feeding with albumin milk, skim 
and buttermilk, and cereal mixtures and whey-cereal 
mixture (Frank) offer the least risk. 

Prolonged starvation by insufficient diet or by refusal 
on the part of the infant to take the prescribed diet is 
always disastrous, and must be avoided. After six, or 
at the most twelve, hours on the tea diet the infant is 
placed on cereal water (barley, rice, or flour ball), using 
1 tablespoonful of the flour to a pint of water in young 
infants, and 2 tablespoonfuls to the pint of water in 
infants over 1 year. After twenty-four to forty-eight 
hours on the above diet an ounce of clear chicken or 
lamb broth can be added to the above cereal waters, 
seasoning with a small amount of salt. If the child will 
take the food, it may be given in the same quantities to 
which the child has been accustomed, or smaller quanti- 
ties at more frequent intervals. 

By far the best results obtained in our private and hos- 
pital work have been by instituting feeding with albumin 
milk of Finkelstein after the first twenty-four hours on 
an inert diet. The value of the albumin milk may be 
explained by the fact that it is easily digestible, contain- 
ing moderate quantities of fat and sugar and finely 
divided casein, which is easily digested in this form. The 
rules to be followed in the feeding with albumin milk 
are described under Decomposition. This diet is also to 



272 INFANT FEEDING. 

be recommended in home practice, wherever it is pos- 
sible to obtain it, either from a neighboring hospital or 
by instruction of the nurse or of the mother. Feeding 
with albumin milk should be begun after twenty-four 
hours on the tea and cereal water diet. Sufficient quan- 
tity of inert fluid, either in the form of water, tea, or 
cereal water should be given with or between the small 
feedings of albumin milk. One of the gravest dangers 
in the severe infections is that the infants are likely to 
take too little rather than too large quantities, and are 
especially prone to vomit when the food is forced upon 
them. 

Boiled skim buttermilk or skim milk with starch or 
flour ball added (1 tablespoonful to the pint) may be 
used as substitute, if albumin milk cannot be obtained. 
They are, however, not so efficacious. They should be 
fed in small quantities, as recommended for albumin 
milk. 

Chymogen milk (either made from the whole milk, or 
in severe types from skim milk), either diluted or in 
small quantities, if given full strength, is frequently re- 
tained when the stomach is very irritable, and where the 
child objects to the less palatable albumin milk and but- 
termilk mixtures. 

The whey-cereal mixture therapy of Frank deserves 
a special mention. It is administered as follows : 

1st day: Initial starvation period on tea for not longer 
than twelve hours. 

2d day : Feed five times 50 grams whey and 50 grams 
cereal gruel prepared from crushed grain. 

3d day: Increase to 60 grams whey and 60 grams 
cereal gruel. 

4th day: 75 grams whey and 75 grams gruel. 



INFECTION AND, NUTRITION. 273 

5th to 8th day: Not later than on the fifth to eighth 
day of treatment replace a tablespoonful of whey by 
tablespoonful of milk. Increases of milk to be guided by 
the infant's progress and needs. 

9th to 11th day: Increase the addition of milk 
gradually. 

12th to 14th day : Even in the grave case 400 grams of 
milk and 400 grams of cereal gruels and 200 grams of 
meat broth must be given, and not later than in this time 
the broth is to be prepared with strained rice or farina. 
In infants over 1 year, beginning with the tenth day, 
finely scraped beef may be added. 

A careful record should be kept of the exact amount 
of milk and other fluids taken in each twenty-four hours, 
and, where possible, the child should be weighed daily to 
ascertain the loss in weight. 

The dietetic therapy has never such a prompt result as 
in alimentary nutritional disturbances. Even in favor- 
able cases the disease (purulent and bloody stools, fever) 
continues for one week; in unfavorable cases, several 
weeks. Strict adherence to the food regime once insti- 
tuted is desirable. In these cases no greater mistake 
could be made than to change diet with introduction of 
repeated hunger days, or to remain on small quantities of 
food. Thus, an infant suffering from infection succumbs 
often not to the infection, not to the nutritional disturb- 
ance, but to inanition. 

Diet in Convalescence. The problem of nutrition 
offers great difficulties, even after the subsidence of the 
fever, and following the improvement in the number and 
character of the stools, as it is frequently necessary to 
keep the infant on a restricted diet for from one to three 
weeks. Only rarely it is possible to feed sufficient caloric 

18 



274 INFANT FEEDING. 

units for the maintenance of weight during the first and 
the second weeks of the illness. Where possible, the 
albumin milk, buttermilk, skim milk, and chymogen milk 
and cereal gruels should be gradually increased, and 
these increases in quantity should be maintained even in 
the presence of moderately bad stools if vomiting is ab- 
sent, unless one becomes convinced that one or the other 
of the food elements is absolutely detrimental to the 
infant's welfare. 

It is our desire to impress that possibly the gravest dan- 
ger to the infant during the period of convalescence is 
that of underfeeding. Upon the return to milk mixture 
small quantities of boiled milk, low in fat (albumin milk, 
buttermilk, skim milk) should at first be used. This may 
be accomplished by adding it to the cereal gruels. Dur- 
ing this stage beef juice broths, tgg albumin, coddled 
egg (prepared as for typhoid fever patients), zwieback 
crumbs, pap, custards, and junket may be added. Under 
conditions where ideal milk and milk preparations can- 
not be obtained, we have found that not infrequently the 
better brand of evaporated milk, as obtained on the open 
market, are useful, when properly diluted. The use of 
condensed milk should be avoided. 

The obstinate constipation which is sometimes seen 
during convalescence should be treated with the utmost 
conservatism along the lines as laid down for constipa- 
tion. The infant should have at least one evacuation of 
the bowels daily. A saline enema is usually sufficient to 
produce this result. 



Appendix. 



PROPRIETARY BABY FOODS. 

It should be borne in mind that the average daily cost 
of many of the proprietary baby foods is in excess of 
twenty-five cents. 

For practical purposes the baby foods may be classed 
as follows: 
Group I. Prepared from cow's milk. 

1. Condensed milk without added sugar. 

2. Condensed milk with added sugar (Borden's 

Eagle Brand) (F., 8.85; P., 7.34; milk-sugar, 
11.61; cane-sugar, 42.9; ash, 1.77; water, 27.53). 

3. Evaporated milk (St. Charles) (F., 9.0; P., 7.82; 

milk-sugar, 11.19; ash, 1.71; water, 69.91). 

4. Peerless Brand unsweetened evaporated milk (R, 

9.27; P., 7.28; milk-sugar, 9.99; ash, 1.51; water, 
71.82). 

5. Carnation Brand. 

6. Lacta Prseparata (powder). 

7. Mammala (powder) (F., 12.12; P., 24.35; milk- 

sugar, 55.34; ash, 5; moisture, 3.19). 

8. Honor Brand powdered milk (F., 12.0; P., 34.0; 

milk-sugar, 44.0; ash, 7,0; moisture, 3.0). 

9. Merrill-Soule powdered modified milk (F., 18.0; 

casein, 8.6; albumin, 7.5; milk-sugar, 57.8; ash, 
7.3; moisture, 1.2). Calories, 133 per ounce. To 
be used 1 part food to from 4 to 10 parts of 
water. 

(275) 



2/6 INFANT FEEDING. 

Group II. Foods prepared from dried cow's milk and 
modified cereals. To be diluted with water only. 

(A) Containing much unchanged starch. 

1. Nestle's Food (milk-sugar, 7.4; maltose, 15.6; 

cane-sugar, 24.77; starch, 17.31; protein, 10.92; 
dextrin, 13.51; fat, 5.63; ash, 1.49; water, 
3.37). 

2. Anglo-Swiss. 

(B) Starch largely converted into soluble carbohy- 

drates, such as maltose and dextrin. 

1. Horlick's Malted Milk (F., 8.5; P., 16.3; mal- 

tose and dextrin, 18.80; lactose, 49.15; ash, 
3.8; water, 3.0). 

2. Allenberry's I and II. (No. I, F., 17.2; P., 10.6; 

maltose, 14.0; dextrin, 10.0; lactose, 42.0; ash, 
3.0.) (No. II, F., 15.88; P., 9.90; maltose, 
20.0; lactose, 36.0; dextrin, 13.0; salts, 3.71.) 
Group III. Foods prepared from modified cereals to be 
used with fresh cow's milk. 

(A) Starch unchanged. 

1. Flours of barley, wheat, rice, corn, oats, soy 

beans, etc. (Barley flour, 1 level tablespoonful 
(98 grains) to 12 ounces water equals 1.27 
starch or 1.8 calories per ounce.) 

2. Arrowroot. 

(B) Starch partially dextrinized. 

1. Robinson's patent barley flour. 

2. Imperial Granum (F., 1.4; P. 14.0; carbohydrates 

(sol.), 1.8; carbohydrates (insol.), 73.5; ash, 
0.39; water, 9.0). (Can be used when flour ball 
is indicated). 



APPENDIX. 277 

3. Eskay's Food (contains a small amount of egg 

albumin) (F., 1.0; P., 6.7; carbohydrates (in- 
sol.), 21.21; carbohydrates (sol.), 67.81; 
ash, 1.3). 

4. Denno's Baby Food (F., 1.79; P., 11.0; cane- 

sugar, 15.2; starch, 64.6; ash, 1.12; water, 
6.2). 

5. Allenberry's No. Ill (malted) (F, 1.05; P., 

10.23; carbohydrates (sol.), 25.00; maltose, 
16.5; dextrin, 8.5; carbohydrates (insol.), 
60.01; ash, 0.60). 
(C) Starch completely changed to dextrin and 
maltose : 

1. Borcherdt's Dri-Malt Soup Extract (maltose, 

71.10; dextrin, 13.50; protein, 8.66; ash, 2.94; 
moisture, 3.80). Calories per ounce by weight 
equals 110. It is a laxative, and is easily di- 
gested because of the high maltose and potas- 
sium carbonate (1.1 per cent.) contents. 

2. Borcherdt's Malt Soup Extract (protein, 6.40; 

maltose, 57.57; dextrin, 11.70; ash, 2.54; mois- 
ture, 21.79). It contains 1.1 per cent, potas- 
sium carbonate. 

3. Borcherdt's Dri-Malt Soup Extract with Wheat 

Flour. Semi-liquid malt soup extract, to 
which gelatinized wheat flour has been added, 
and the whole dried. One ounce equals 110 
calories. 

4. Borcherdt's Malt Sugar (dry) (maltose, 87 per 

cent.; dextrin, 5 per cent.). The following 
table will give a comparative idea of the rela- 
tive value by weight and measure of Bor- 
cherdt's liquid and dri-malt soup extracts: 



278 INFANT FEEDING. 

16 Fluid oz. equal 19.5 oz. dry malt powder by measure. 
1 Fluid oz. equals, 1.2 oz. dry malt powder by measure. 
1 oz. of liquid by weight equals 0.83 oz. of powder. 
1 Fluid oz. represents 90 calories. 
1 Ounce of powder by weight represents 110 calories. 

5. Horlick's Malt Food (contains no milk) (F., 1.40; 

P., 12.06; carbohydrates (chiefly maltose), 
81.97; ash, 2.60; water, 1.97. Calories, 109.29. 

6. Mellin's Food (F., 0.16; P., 10.35; maltose, 

58.88; dextrin, 20.69; carbohydrates (sol.), 
79.57; salts, 4.3; water, 5.6). Calories, 91.43. 
It contains 2 per cent, of potassium bicarbonate. 

7. Dextri-maltose (Mead's No. 1) (maltose, 52; 

dextrin, 41; water, 5; sodium chloride, 2). No. 
2 (maltose, 53; dextrin, 42; water, 5). No. 3 
(maltose, 52; dextrin, 41; water, 5; potassium 
carbonate, 2). 

8. Nahrzucker (Sohxlet) (F., 0.03; P., 0.13; mal- 

tose, 41.0; dextrin, 53.3; ash, 1.7; water, 2). 
Group IV. Foods prepared from casein. 

1. Larosan (casein plus calcium). 

2. Nutrol (sodium compound of casein). 

3. Plasmon (from casein by action of C0 2 and 

NaHCO s ). 
Group V. Diastatic ferments. 

1. Diastoid (Horlick's, powder). 

2. Diazyme (Fairchild, liquid), a good product. 
Group VI. Peptonizing powders. 

1. Peptogenic milk powder (Fairchild's). 

2. Pepsin. 

Group VII. Rennet powders (precipitating curd in a 
finely divided form). 

1. Chymogen (rennin and milk-sugar). 

2. Pegnin (rennin). 



APPENDIX. 279 

It will be noticed that there are two great classes of 
proprietary infant foods: 

The First. (Groups I, II). Those containing cow's 
milk. 

Sweetened Condensed Milks. These are advertised as 
complete infant foods. All of them are quite similar in 
composition. All contain large amounts of cane-sugar. 
It is impossible to make, by simply adding water, a 
properly balanced food for an infant's continuous diet. 
A dilution to give a rational amount of proteins and fats 
has a large excess of sugars, and one to contain any 
amount under 7 per cent, total sugar would be so weak 
in both protein and fat that the baby's proper growth 
would be very seriously interfered with. 

Eagle Brand condensed milk contains: fat, 8.85; pro- 
teins, 7.34; milk-sugar, 11.61; cane-sugar, 42.90; ash, 
1.77; water, 27.5. 

TABLE. 

A Well-known Condensed Milk, Showing the Content 
of Various Dilutions. Fats and Proteins Deficient. 

Full 6 parts 12 parts 18 parts 

strength water water water 

Per cent. Per cent. Per cent. Per cent. 

Fat 6.94 .99 .53 .36 

Proteid 8.43 1.2 .65 .44 

Cane-sugar . . . 50.69 7.23 3.90 2.67 

Salts 1.39 .17 .10 .07 

Water 31.30 90.49 94.80 96.46 

The Unsweetened Evaporated Milks. They were made 
by heating the milk to 200° F., and then transferring it 
to vacuum pans, where it is maintained at a temperature 
of 125° F., until sufficient water is evaporated to bring 
the product to the required condensation. In most 
products this milk is about double strength. 



280 INFANT FEEDING. 

The sugar content not being in excess, these milks can 
be so diluted that a reasonable amount of fat and protein 
can be obtained, with, however, a considerable deficiency 
in sugar; this relatively low amount of carbohydrate can 
then be made up by adding sugar (cane or maltose-dex- 
trin compounds), much the same as is done with cow's 
milk. Where it is impossible to obtain clean, fresh milk, 
evaporated milk can be used with good success as a tem- 
porary diet in traveling, etc. A fresh can should be 
opened daily. It can be diluted with three to six or more 
parts of water, or cereal water and sugar in some form 
as indicated; however, the carbohydrates contained in 
the formula should rarely exceed 7 per cent. One part 
of milk to two parts of diluent plus carbohydrates is the 
strongest formula in which it is ever necessary to feed 
infants, as this equals the strength of whole milk with 
carbohydrate added. 

Occasionally, infants with a very weak digestion ' will 
thrive on the evaporated milk where all other methods 
fail, if the food is started in high dilution, the quantity be- 
ing increased as the infant shows improved capacity. 

Because of the repeated heating and the low salt con- 
tent, the food necessarily loses some of its vital require- 
ments, and an early attempt to change to fresh milk 
should be made in order to avoid constitutional disorders 
as rachitis, scurvy, etc. The tendency to become very 
fat on this class of foods is proverbial, but this is not 
usually associated with high resistance or immunity to 
infections, and these infants succumb rapidly to the 
respiratory and intestinal infections. Unless the mother 
is forewarned, it is often with reluctance that she can be 
made to foresee the necessity of taking her baby off the 
fbod which agrees with it, and experiment with a new 
and occasionally uncertain formula. 



APPENDIX. 281 

The Powdered Milk Foods. Mammala, Honor Brand, 
and Merrill-Soule Brand are fresh milk dried. In the 
two former, part of the cream has been removed. All 
have some lactose added. They find their most impor- 
tant indication as an occasional substitute feeding in 
breast-fed infants — first, for the mother's convenience, 
to allow her recreation; secondly, where the milk of the 
mother is insufficient, and one or two regular feedings 
are indicated temporarily until a formula of fresh milk 
is advisable, or while traveling, when the milk supply is 
uncertain; and thirdly, those containing large amounts 
of maltose (Horlick's) can be given once daily in breast- 
fed infants in need of a laxative. 

The Second Class. Those to be used in conjunction 
with fresh cow's milk. In this class belong Groups III 
and IV. These give us a far more rational infant food. 

Group III. (A) The unchanged or partially dextrin- 
ized starches are especially to be used in solution in place 
of boiled water as diluents, best after the second month. 
A number of good cereal flours can be purchased on the 
market. 

(B) In this group are found most of the highly ad- 
vertised and detailed baby foods. They have little or 
no advantage over the plain cereal flours. 

(C) These are especially valuable where maltose and 
dextrin are better taken than cane- or milk- sugar. Dex- 
tri-maltose (Mead's No. 1 and 2) and Nahrzucker. 

DIRECTIONS FOR THE PREPARATION 
OF INFANT'S FOODS. 

Tea. 

To a small half-teaspoonful of fennel, chamomile, or 
"green" tea add 1 pint of boiling water, cover with a, 



282 INFANT FEEDING. 

clean dish, and steep for two or three minutes, or till the 
tea is of a light yellow color; then pour through a clean 
sieve or muslin. It should be weak. If used for thirst 
only, in diarrheal cases, one-fourth of the above amount 
is sufficient. 

Barley Water. 

Soak 2 tablespoonfuls of washed barley (pearl) in 
water overnight; pour off water, add 1 quart of fresh 
water, and boil down to 1 pint (2 hours). Add boiled 
water to make 1 pint, if necessary. Strain through fine 
cloth. Keep in ice-chest. 

Oatmeal and Rice Water. 

They are prepared in the same manner, only boiled 
more slowly. They may be made from barley, oatmeal, 
or rice flours by using 1 rounded tablespoonful to lj^ 
pints of water, and boiling for 20 minutes down to 1 
pint, in an open stew-pan, stirring constantly. (Ap- 
proximates 3 calories per ounce). In preparation of a 
feeding formula they can be prepared in a more con- 
centrated form if indicated. 

Oatmeal, Barley, and Wheat Jelly. 

Use twice the quantity of cereal and same quantity of 
water. 

To Dextrinize Barley or Oatmeal Water. 

Cool to 105° F., add 1 teaspoonful extract of malt, 
cereo, liquid taka-diastase or diazyme, stir, allow to 
stand for 15 minutes, when the gruel becomes thin and 
watery. Add a pinch of salt, stir, only to mix, cool, 
Strain, and put in ice-chest. 



APPENDIX. 283 

Flour Ball. 

Tie 2 pounds of wheat flour in a cheese-cloth bag, and 
boil in 2 quarts of water for five hours. Remove from 
water; place in oven until quite brown on the outside. 
This will require from two to three hours slow baking. 
Break open and throw away the brown shell; the re- 
mainder, the baked flour, must then be grated into a 
powder, or may be ground in a mill. 

Albumin Water. 

To y 2 cup of cold boiled water add the white of 1 fresh 
egg and a pinch of salt. Stir very thoroughly. A piece 
or two of artificial ice may be added before stirring. 
One-half teaspoonful of sugar and orange juice may be 
added, if not contraindicated. Barley water may be used. 

Albumin Water with Beef Extract. 

One-quarter teaspoonful of beef extract may be added 
to the cold water before adding the egg albumin. 

White of Egg and Digested Gruel. 

Whites of 2 eggs may be added to 1 pint of dextrin- 
ized barley, oatmeal, etc., gruels. Stir thoroughly. 

Pasteurized Milk (double boiler). 

Place milk in cold water bath, having water to level of 
milk; bring milk to temperature between 155° and 
167° F. for 15 to 20 minutes. 

Sterilized Milk (double boiler). 

The milk mixture is put into the inner vessel cold, and 
the water in the outer vessel is also cold. The double 



284 INFANT FEEDING. 

boiler is then placed on the stove and allowed to remain 
until the water in the outer vessel boils for 6 to 8 min- 
utes; the whole process requires 10 to 15 minutes. 
While the milk heated in this manner forms a much finer 
and softer curd than that of raw milk, it is not as fine 
as the milk boiled directly over the flame. 

Whey. 

Heat 1 quart of clean raw milk to 104° F., and add 1 
level teaspoonful of chymogen or fresh essence of pep- 
sin (Fairchild's). Allow it to stand for one-half hour, 
pour off the free whey, pour the curd into a straining 
cloth for one-half hour, and collect the remainder of the 
whey. 

Chymogen Milk. 

Boil milk for five minutes, cool to 104° F., and add 1 full 
teaspoonful of chymogen to each quart of milk, and stir 
for one-half minute. Let it come to a clabbard by allow- 
ing it to stand for 15 minutes; then beat it well until the 
curd is finely divided. Do not heat above 100° F., when 
preparing individual bottles for feeding, otherwise curds 
will clump, and will not pass through the nipple. 

Indications for chymogen milk: (1) Vomiting in in- 
fancy; (2) indigestion due to the large curd formation. 

Buttermilk in the Home. 

A pure culture of lactic acid bacilli is added to raw, 
pasteurized, or boiled milk in an earthenware dish, and 
allowed to stand at about 80° F. for 15 to 20 hours, or 
until the casein is coagulated. Stir vigorously in a churn, 
or with a spoon or egg-beater until the curd is very small, 
and then push the contents through a fine wire strainer 



APPENDIX. 285 

with a spoon. If the buttermilk is too thick, add a small 
amount of water. When the buttermilk is once made, 
a small portion (about 4 ounces) may be used as the in- 
oculating agent for the next supply to be made. In this 
way the original culture may be made to last from six 
to eight weeks. The quality and action of the product 
made will vary but little. Add 4 ounces of buttermilk to 
1 quart of fresh milk, incubate, and follow the above 
outline. Sometimes the milk will not coagulate, although 
it may smell sour. Stirring with a spoon will often pro- 
duce coagulation in a few minutes. The fat present will 
rise to the top, and when coagulated appears as a brown- 
ish-yellow scum, which may be removed before the curd 
is broken up. At the present time the market is flooded 
with tablets for the preparation of buttermilk, but one 
must hesitate before using them to prepare milk for a 
baby. A pure culture should be used, or one recom- 
mended by the physician. Whole or skim milk is to be 
used as indicated in each individual case. 

Startoline. 

Carefully pasteurize 2 quarts of fresh whole milk to a 
temperature of 180° F. for one hour, or boil for five 
minutes ; cool quickly to about 80° F., and add 1 ounce 
of Hanson's Lactic Ferment Culture, and let it stand un- 
disturbed until well curdled, which should be in 15 or 20 
hours, at a temperature of 75° F. Then place on ice. 
When ready to use, beat curd up with a spoon until it is 
of a creamy consistency. 

Buttermilk for Hospital Feeding. 

Pasteurize whole sweet milk to a temperature of 180° 
F. for one hour; then place in cold water until cooled to 



286 INFANT FEEDING. 

80° F. Add 1 ounce of startoline to every quart of milk, 
stir with a spoon, and cover; allow to stand from 15 to 
20 hours, then churn for one hour ; then add a little cold 
sterile water to break butter away from milk ; and strain 
buttermilk. 

Buttermilk and Skim Milk Mixture. 

To a few tablespoonfuls of buttermilk or skim milk 
add 2% level tablespoonfuls of flour (flour ball or dex- 
trinized barley flour), to make a paste. Make up to 1 
quart with buttermilk. (1) Bring to a boil, withdraw 
from fire. (2) Bring to a boil, withdraw from fire a 
second time. (3) Add 4 level tablespoonfuls of cane- 
sugar, and bring to a boil for the third time. (Maltose- 
dextrin preparations are best in all diarrheal conditions.) 
(1, 2, and 3 should require about twenty minutes time.) 
Make up to 1 quart with boiled water, if it has boiled 
away; put on ice. It is well to start with one-half the 
amount of sugar, and increase as indicated. 

Indications for buttermilk and skim milk mixtures : 

1. Fat indigestion. 

2. Loose bowels (it may be necessary to reduce the 

amount of sugar. The high protein contents 
tends to constipate). 

3. Malnutrition, with stationary weight. 

Brady's Mixture No. 1. 

Dr. Jules Brady, of St. Louis, has suggested the two 
mixtures following, which contain less carbohydrates 
than the above buttermilk mixture, and which he has 
found especially valuable in the feeding of infants in 
institutional practice. 



APPENDIX. 287 

Mixture No. 1, which is used for young infants during 
the first two months, contains 11 calories in each ounce; 
the young infant receives 4 ounces of this mixture for 
every pound of body weight as soon as it will take it. 
The baby weighing 6 pounds at birth is allowed to take 
24 ounces in twenty-four hours, or 3.5 ounces every three 
hours, 7 feedings in twenty-four hours. The average in- 
fant at three or four days will take 1 ounce; at eight 
days, 1 to 2 ounces; at fourteen days, \y 2 to 2 ounces; 
at three weeks, 2 ounces ; at six weeks, 3 ounces ; at eight 
weeks, 4 ounces. 

Mixture No. i. 

^4 quart buttermilk or skim milk. 

Y^ quart barley water (thick). 

1 ounce by measure, Mellin's Food. 

y 2 ounce granulated sugar. 
The ingredients are mixed together in the following 
manner: To the barley gruel is added the cane-sugar 
and the Mellin's Food, and then the milk is slowly added, 
and the mixture strained. As a rule, the milk is acidi- 
fied with lactic acid bacilli twelve hours before being 
made up, having first agitated it. 

Brady's Mixture No. 2. 

On reaching a weight of 8y> to 9 pounds, infants re- 
ceive the mixture No. 2, which contains 18 calories for 
every ounce. The babies are allowed 3 ounces of the 
mixture No. 2 for every pound of body weight. 
Mixture No. 2. 

% quart whole fresh milk or whole buttermilk. 
% quart barley water (thick). 
1 ounce granulated sugar. 



288 INFANT FEEDING. 

Keller's Malt Soup. 

To 11 ounces (330 Gm.) of warm milk gradually add 
1% ounces (50 Gm.) of flour, stir constantly, then pour 
through a clean sieve or muslin. In another dish dis- 
solve 3 ounces (100 Gm.) by weight, or 2y 2 ounces or 
tablespoonfuls by measure, of Borcherdt's malt extract 
with potassium carbonate in 20 ounces (600 Gm.) of 
boiled warm water. Then mix both solutions, put on 
fire, stir continually, and boil for two or three minutes. 

Indications for Keller's Malt Soup : 

1. Fat indigestion. 

2. Disturbed metabolic balance (fat-soap stools). 

3. Chronic constipation (often relieved by simple 

addition of malt soup extract to ordinary milk 
mixture in place of part of sugar). 
Contraindications: 

1. Before the third month, if the stools are loose. 

2. For a period of more than four to eight weeks 

(to be followed, where possible, by ordinary 
milk mixtures, the strength of the latter being 
gradually increased). 

Cream Soups. 

Cream soups may be made from vegetable pulp, using 
1 tablespoonful of cooked potatoes, peas, or asparagus to 
y 2 cup of water in which the vegetables were cooked, y 2 
cup of sweet milk, and Yz teaspoonful of flour, with a 
little butter and salt. Cook another minute or two. 
Strain if necessary. Serve. 

Corn or tomatoes may be used in the same manner, 
using 2 tablespoonfuls of strained vegetables, with 
about one-third water and two-thirds milk. When 



APPENDIX. 289 

tomatoes are used, add a small pinch of soda to tomatoes 
before adding other ingredients. 

Vegetable Soup. 

One-fourth pound lamb stew, cut into pieces, 1 potato 
cut into pieces, 1 carrot cut into pieces, 2 stalks of celery 
cut into pieces, 1 tablespoonful of pearl barley, 2 table- 
spoonfuls rice, 2 quarts water. Boil down to 1 quart; 
boil three hours. Add pinch of salt, and strain before 
feeding. 

Lamb, or Veal Broth. 

Lean meat chopped fine, 1 pound ; cold water, 1 quart ; 
a pinch of salt; cook slowly two or three hours to 1 pint. 
Add water from time to time, so that when finished there 
will be 1 pint of broth. Strain ; when cold, skim off fat. 

Chicken Broth. 

Small chicken, or one-half of large fowl, with all skin 
and fat removed ; chop bones and all into small pieces ; add 
1 quart boiling water and a little salt ; cover closely, and 
allow to simmer over a slow fire for two hours. After 
removing allow to stand one hour; then strain. Add 
water, if necessary, from time to time, so that there will 
be 1 pint when finished. 

Farina Soup. 

To 1 pint of meat broth, gradually add, while stirring, 
1 even tablespoonful of farina, and boil down to 1 cup 
(y 2 pint) in about twenty minutes. It is a good plan to 
boil the farina for from fifteen to twenty minutes before 
adding it to the broth ; then broth and farina need to be 
boiled together for but ten minutes. 

19 



290 INFANT FEEDING. 

Dried Fruit Soup. 

Wash thoroughly 1 cup of dried apricots and 1 cup of 
prunes. Cook in 1 quart of cold water until very soft. 
Strain and press out all juice. Sweeten to taste. Thicken 
with a tablespoonful of rice flour to 1 quart of the liquid. 
Cook twenty minutes to remove the raw taste of the 
flour. 

Soy Bean and Condensed Milk (Ruhrah). 

Add a level tablespoonful of soy bean flour to 2 level 
tablespoonfuls of barley flour, add a pinch of salt, and 
mix to a paste with boiled water, adding further water to 
1 quart. Boil for twenty minutes, and add water to make 
up for the loss due to evaporation during boiling, so that 
total mixture is 1 quart. Condensed milk is now added, 
varying in quantity from y 2 to 1 dram of condensed 
milk to each ounce of the mixture, depending upon the 
age and the condition of the infant. Double the quantity 
of soy bean and barley flours may be used for older chil- 
dren. Each ounce of soy bean gruel contains 10 grams of 
protein and 102 calories. Two ounces of soy bean gruel 
in a quart of water contains 0.56 per cent, protein, 0.62 
per cent, fat, and 3.31 per cent, sugar. 

The quantity of the feedings may be varied according 
to the condition and needs of the infant, varying from 1 
to 8 ounces per feeding. 

It is indicated whenever fresh clean milk is not ob- 
tainable, in infants with marasmus, in some intestinal 
disturbance associated with diarrhea. 

Beef Juice. 

Take % to ^2 pound round steak, broil slightly, cut 
into small pieces, and then press out the juice with a meat 



APPENDIX. 291 

press or potato ricer, and add a small pinch of salt. Feed 
fresh, or warm before giving, but do not heat sufficiently 
to coagulate albumin. 

Potatoes. 

Boil potatoes in salt water in the ordinary way until 
they are thoroughly done. Then mash through a very 
fine sieve, and add a little butter. 

Spinach. 

Cook spinach in salted water until tender. Pour cold 
water over it, and drain. Chop fine, or rub through a 
coarse sieve. To 2 tablespoonfuls of spinach add 1 tea- 
spoonful of fine breadcrumbs, Yz teaspoonful melted but- 
ter, and a little salt. Reheat and serve. 

Asparagus. 

Cook one-half of a bunch of asparagus in about a pint 
of slightly salted water. When tender, remove stalks one 
by one. Place on a warm plate, and remove pulp by 
taking hold of the firm end of the stalk, scraping lightly 
with a fork towards the tips. Use pulp only. Make a 
sauce with one-fourth of a cup of water in which 
asparagus was cooked, one-fourth, of a cup of milk, 1 
teaspoonful flour, a little butter and salt. Dip a small 
piece of toast in the sauce. Take what is left of the 
sauce and mix with 2 tablespoonfuls of asparagus pulp. 
Reheat. Place on toast and serve. 

Carrots. 

Cook y 2 pound of young carrots in a pint of fat-free 
soup stock or slightly salted water, adding more if it 



292 INFANT FEEDING. 

cooks away before they are done. Rub through a sieve ; 
add 1 teaspoonful of bread-crumbs, a little butter and 
salt. Reheat and serve. 

Beans. 

Soak 2 ounces or 4 tablespoonfuls of beans, and cook 
them slowly in a good deal of water until they are soft, 
but not broken. Rub through a sieve, add 1 cupful of 
soup stock, and let them cook for one-half hour, adding 
more stock if it boils away. Mix a little butter and flour, 
about a teaspoonful of each, and a little salt. Add to 
soup. Return to fire, and cook for a few minutes. 

Green Peas. 

Cook a cupful of green peas in boiling salted water 
until they are done. Drain, saving the water in which 
they are cooked. Rub through a coarse sieve. Make a 
sauce of 2 tablespoonfuls of water in which the peas 
were boiled, 2 tablespoonfuls of sweet milk, y 2 teaspoon- 
ful flour, y 2 teaspoonful fine bread-crumbs. Mix all 
together. Reheat and serve. 

Fruits. 

(a) Orange Juice: Take sweet orange, cut into halves, 
and squeeze out juice by hand or with a lemon squeezer; 
strain, put on ice, and use as ordered. 

(b) Prune Juice: Take y 2 pound of prunes, wash 
thoroughly, cover with cold water, and soak overnight. 
In the morning place on stove in the same water, and 
cook until tender. Add 1 teaspoonful of sugar, and 
strain. 

(c) Prune Jelly: Cover 1 pound of prunes with 1 
quart of water; cook slowly until tender; pit, and press 



APPENDIX. 293 

pulp through a sieve. Add sugar to sweeten (2 tea- 
spoonfuls) and j/2 box of gelatin dissolved in a pint of 
water, and boil. Strain, cool, and keep covered. 

(d) Apple Sauce: Take 6 apples and peel, core, and 
cut them into quarters. Place them in an enameled dish ; 
sprinkle over them 1 tablespoonful of sugar; add 1 cup 
of cold water; put the dish on the stove, and boil the 
apples to a mush (about thirty minutes). 

(e) Orange Gelatin: Soak y 2 box of shredded gelatin 
in cold water for thirty minutes. Add 2 cupfuls of boil- 
ing water, and dissolve. Then add 1 cupful of sugar, 
the juice of 1 lemon, and a cupful of orange juice. 
Strain through a fine strainer (or a cloth) into moulds, 
and set away to harden. 

Eggs. 

Use only soft-boiled or poached eggs. Be sure that 
the eggs are fresh. Drop egg in boiling water; imme- 
diately turn flame out, and allow to stand for five 
minutes. 

Pap. 

Put 1 pint of milk on to boil ; add butter the size of a 
walnut. Beat 1 egg thoroughly. When milk boils, add 
the beaten egg, stirring constantly. Mix \y 2 tablespoon- 
fuls flour into a paste and add to mixture, stirring con- 
stantly. Allow mixture to boil ten minutes. Just before 
taking from the fire add a pinch of salt. May be taken 
plain, or with milk and sugar as directed. 

. Cornstarch Pudding. 

Take 1 pint of milk and mix with 2 tablespoonfuls of 
cornstarch; cane-sugar, 1 tablespoonful. Flavor to 



294 INFANT FEEDING. 

taste; then boil the whole eight minutes. Allow to cool 
in a mould. 

Custard Pudding. 

Break 1 egg into a teacup and mix thoroughly with 
sugar to taste. Then add milk to nearly fill the cup. 
Mix again, and tie over the cup a small piece of linen. 
Place the cup in a shallow saucepan half full of water,- 
and boil for ten minutes. 

If it is desired to make a light batter pudding, a tea- 
spoonful of flour should be mixed in with the milk be- 
fore tying up the cup. 

Infant's Gelatin Food. 

About 1 teaspoonful of gelatin should be dissolved by 
boiling in y 2 pint of water. Toward the end of the boil- 
ing, y^ pint of cow's milk and 1 teaspoonful of arrow- 
root (made into a paste with cold water) are to be 
stirred into the solution, and 1 to 2 tablespoonfuls of 
cream added, just at the termination of the cooking. It 
is then to be moderately sweetened with white sugar, 
when it is ready for use. The whole preparation should 
occupy about fifteen minutes. 

Albumin or Eiweiss Milk (Finkelstein). 

One quart. Take fresh whole milk, bring to a tem- 
perature of 98° to 100° F. Then add 2 level tablespoon- 
fuls of chymogen powder to a quart of milk; place in a 
water bath of 107° F., for fifteen to twenty minutes, 
until coagulated. Then hang in a sterile muslin bag for 
one hour to drain. 

To the curd of 1 quart of milk add 1 pint of buttermilk, 
and rub through a copper gauze strainer three times. 



APPENDIX. 295 

Then add 2 level tablespoonfuls of wheat flour, flour 
ball, or imperial granum, rubbed to a paste with 1 pint 
of water. Boil ten minutes, cutting back and forth con- 
stantly, not stirring, with a large wooden spoon, other- 
wise large curds will form. If needed, water should 
again be added, to make the finished mixture one quart. 
Finkelstein advises the early addition of 3 per cent, of 
carbohydrate in the form of a maltose-dextrin compound. 
This is best done by dissolving the sugar in a moderate 
quantity of water, and adding while the mixture is being 
boiled. It must not be heated above 100° F. before feed- 
ing, otherwise it will clump. 

Albumin milk contains : protein, 3 per cent. ; fat, 2.5 
percent.; milk-sugar, 1.5 per cent.; starch, 1.0 per cent.; 
salts, 0.5 per cent. Caloric value is 450 calories per liter, 
or 12 calories per ounce. 

Indications for albumin milk (Finkelstein) : 

1. Diarrheas and all cases of abnormal intestinal fer- 

mentation (sugar). 

2. Fat indigestion with low sugar tolerance. 

3. Gastro-intestinal infections associated with fre- 

quent stools. 

4. Systemic infections with intestinal complications. 

Albumin Milk (Miiller and Schloss). 

Use 1 quart of water and 1 quart of buttermilk, and 
boil for three minutes. Set aside for thirty minutes, and 
then pour off the upper 36 ounces of the whey. Boil the 
upper 4.5 ounces of a quart of fresh milk for three min- 
utes. Add 1 ounce of dextri-maltose to the boiled top 
milk, and to this add the curds from the first mixture, 
which would equal 27.5 ounces, making 1 quart of the 
milk mixture. 



296 INFANT FEEDING. 

Larosan Milk.. 

Two-thirds of an ounce of Larosan powder (p. 
276) is added to y 2 pint of milk, and mixed thoroughly. 
Another whole pint of milk is heated to the boiling point. 
When it has come to a boil, it is added to the Larosan 
milk mixture, and the whole is placed on the flame and 
allowed to boil for five minutes. This may be diluted 
with water in the proportion of one-half Larosan milk 
and one-half water, or two-thirds Larosan milk and one- 
third water. 




Fig. 16. — Utensils needed for artificial feeding: Double 
boiler (small), pan, funnel, bottle-brush, 250-mil (8 oz.) 
graduated glass or pitcher, 6 nursing bottles and rack, 
paper caps for bottles (sterile), nipples, milk; sugar, flour, 
milk magnesia, citrate of soda, tablespoon, dairy ther- 
mometer, vegetable mill. 

This mixture, because of its high protein content and 
comparative ease of preparation, can be used as a substi- 
tute for albumin milk in the home. 

Meats. 

Raw or slightly cooked beef, scraped and seasoned, 
can be fed in amounts equaling a tablespoonful at 
eighteen months or sooner, once daily. 



APPENDIX. 297 

Take meat, preferably from the round, free from fat. 
Place on a board and scrape with a silver spoon. When 
you have the desired amount of meat pulp, shape into a 
pat and broil on a hot, dry spider. Do not cook too long. 
When done, season with a little salt and butter. Serve. 
A few drops of lemon juice may be added. 

Later, lamb, beefsteak, roast beef and chops are the 
best, and should be broiled. By no means fry any meat 
for the baby. Soup meat, well cooked, may also be given. 
All meats should be very finely cut before giving them 
to children. 

BOTTLES AND NIPPLES AND THEIR CARE. 

The nursing bottle should be of such a construction 
that every portion of it is easily reached with a proper 
brush. This necessitates the avoidance of sharp corners 
and angles, and makes the smooth stream lines in its 
construction desirable. It should be made of good glass, 
not easily broken, capable of being boiled repeatedly 
without cracking, and should hold about 8 to 10 ounces. 
Several nursing bottles should be kept on hand, and, if 
possible, as many bottles as there are nursings in a day 
should be available, so that the whole day's feeding may 
be prepared according to the particular formula, and the 
mixture then iced, and the individual bottles warmed on 
a water-bath whenever necessary. New bottles should 
be annealed by placing them in a vessel with cold water, 
and then bringing the water to a boil, boiling for twenty 
minutes, and then leaving the bottles in this water until 
it will cool off again. Bottles thus treated do not crack 
so easily when hot fluids are poured into them. After 
nursing, the bottle should immediately be rinsed with 
cool water, and then washed with hot water and soap 



298 



INFANT FEEDING. 



suds by means of a bottle brush. Afterwards the bottle 
should be set aside, inverted, so as to drain. Before use, 
the bottles should be boiled for five minutes. To avoid 
cracking, they must be placed in cold water and heated 
slowly. After the food has been prepared, the individual 




Fig. 17. — Good and bad nursing bottles. 1. Ordinary 
small-neck nursing bottle as sold in drug stores (8-ounce). 
2. Improved large-neck nursing bottle (made in 5- and 10- 
ounce size). 3. Hygiea nursing bottle. 

bottles may be filled and stoppered with sterile cotton, or, 
better, sterile paper caps, which are sold for this purpose. 
Nipples that can be turned inside out and easily 
cleansed should be selected. The conical shaped nipple is 
preferable. The hole in the nipple should be of such size 
that the milk will drop rapidly and not flow when the 
bottle is inverted. New nipples should be boiled before 



APPENDIX. 



299 



they are used. After using, every nipple should imme- 
diately be washed with soap and water, being turned in- 
side out, boiled and finally dropped into a sterile jar, 
where it is to be kept dry until ready for use again. 
Keeping the nipples dry lengthens the life of the rubber. 
Several nipples should always be kept on hand. 




Fig. 18. — A milk station consisting of three rooms. Room 
1. For all used bottles, bottle washers, and steam bottle 
sterilizers. Room 2. A clean room for preparation of for- 
mulae. This room also contains milk separator, fat-test- 
ing apparatus and butter churn. Room 3. Pasteurizing and 
sterilizing apparatus. 



CARE OF FOOD DURING TRAVELING. 

Whenever possible, the baby should be kept on its 
usual diet during the long journey. This is usually ac- 



300 INFANT FEEDING. 

complished without much difficulty when the baby is on 
boiled milk. If it has been fed on a raw milk mixture, 
the milk must be boiled before starting. When for any 
reason it is impractical to carry the milk mixture, evap- 
orated milk or powdered milk may be used. (See Pro- 
prietary Infant Foods, p. 273.) In the use of evaporated 
milk, a fresh can must be opened at least once daily. 
When it is known that the baby's formula is to be 
changed, it should be tried out on the new food before 
starting on the journey. As soon as possible, the pre- 
vious diet should be re-established. All water given to the 
baby while traveling must be boiled. The infant's food, 
after boiling for at least ten minutes, should either be 
placed in individual nursing bottles, or in bottles holding 
not more than 1 pint, so that not more than two or three 
feedings should be given from a single bottle. The 
bottle should be packed in ice, using care so that none of 
the ice reaches the top of the bottle. Upon reaching the 
train they should be placed in the ice-box of the dining 
or buffet car, unless a private ice-box is available. The 
baby's bottle can be warmed on the train by setting in a 
dipper of warm water, which may be carried hot in a 
thermos bottle, if the journey is to be a short one. Care 
must be taken that the water be not too hot, otherwise the 
cold bottles will be cracked. The nipples may be carried 
in a wide-mouthed, well-corked bottle, sufficient to cover 
the individual feedings. The nipples and bottles should 
be cleansed immediately after use. 

THE DIAPER. 

The diaper should be made of soft, light, and ab- 
sorbent material, such as cotton diaper cloth, which can 
be purchased for this purpose. Cotton-flannel is toS little 



APPENDIX. 301 

absorbent, and soon becomes hard as a result of washing. 
A second diaper may be folded into a square, and be 
laid under the hips to prevent the moisture from reach- 
ing the clothes, or instead of this arrangement, which is 
rather heating and bulky for summer use, a small diaper 
may be folded two or three times to form a square of 
about nine inches, and this may be placed inside of the 
larger diaper to receive the urine and feces. About four 
dozen diapers are needed for an average baby. 

A rubber or waterproof cover should never be applied 
outside the diaper. It is very heating, and liable to pro- 
duce chafing and eczema. Diapers should be changed as 
soon as soiled, except at night, when they should be 
changed when the child is awakened for feeding, or 
when it is awakened by its own discomfort. Soiled 
diapers are always a source of discomfort, and not infre- 
quently the cause of severe irritation of the skin, as well 
as of infections of the genital and urinary tracts. This 
is especially true in the case of female infants. No diaper 
should be applied a second time without first being 
washed. All diapers which have been soiled by dis- 
charges from the bowel should have the bulk of the feces 
removed from the diaper, and should be immediately 
washed with soap not too alkaline in character, and later 
boiled for twenty minutes, and thoroughly rinsed, so that 
all alkali may be removed. They should then be aired 
thoroughly. Soda and washing-powders should be 
avoided because of the danger of irritating the child's 
buttock's, after being moistened by the urine. 

The diapers of an infant ill with an intestinal infection 
should be cared for separately from those of other chil- 
dren. After changing the diapers, the nurse's hands and 
nails should be scrupulously cleansed with brush and file. 



302 INFANT FEEDING. 

BABY'S DAILY BATH. 

The baby should be bathed at least once a day, and on 
hot days even as many as three sponge-baths may be 
given. In the first six months the temperature of the 
bath should be 100° F., and in the second half of the 
year from 90° to 95° F. The room in which the bathing 
is done should have a temperature of at least 70°, and 
not more than 75° F. 

Toward the end of the first year the infant may be 
sprayed for 15 to 30 seconds with water at 75° to 80° F. 
This should be followed by brisk rubbing of the entire 
body. In young infants the bath is most conveniently 
given before the mid-morning feeding, and the face and 
hands may be sponged before the 6 o'clock feeding. In 
older infants, a cool sponge and massage may be given in 
the morning, and the warm bath at bedtime. 

Before the umbilical cord has separated, sponge-bath 
only should be given, and never a submersion bath, for 
the fear of infection of the umbilical stump. Sponge- 
bath may be given on a towel, and when a tub-bath is 
given, the child should be allowed to rest upon the at- 
tendant's left arm, w T hich is slipped under its back from 
the baby's right side. By grasping the baby under the 
armpit with the left hand a good hold is secured, which 
prevents slipping. The right hand is left free for wash- 
ing the baby. A special wash-cloth, preferably of cheese- 
cloth, should be provided for washing the baby's face and 
head. 

A pure, bland, white soap should be used. Very little 
soap is needed for cleansing the baby's skin, and it is 
most important that the skin should be thoroughly rinsed. 
If the skin is sensitive and easily irritated, soap should be 
avoided, and the bran-bath (made by putting a handful 



APPENDIX. 303 

of bran in cheese-cloth bag and soaking this in the water 
until milky) should be used. 

After the bath the baby should be wrapped in a large 
soft towel and dried by sponging, and not by rubbing. 
Special attention should be paid to folds and creases of 




Fig. 19. — Hospital bathroom. Located between two small 
wards for infants, showing two metal water jackets rest- 
ing on a porcelain sink. These can be filled with water, and 
have a registering thermometer for indicating the tempera- 
ture before giving the bath. They are covered with a clean 
towel for each baby. Baby is showered from an automatic 
mixing tank, which registers temperature of the water in 
the tank. The room further contains a scale and a low 
dressing table, with the various dressings, powders and 
ointments to be used. Also low nursery chairs, collapsible 
bags for soiled linen, and waste basins. 



304 INFANT FEEDING. 

the skin, and these should be well powdered after being 
thoroughly dried. 

Only warm baths should be used in infants who be- 
come pale and cyanotic when a cooler bath is used. 

Care should be taken in bathing all children suffering 
from coughs. Great care should also be used while bath- 
ing a child suffering from vulvovaginitis, to avoid infec- 
tion of the eyes. 

COLD BATH AND COLD PACK. 

Cold bath is an efficient antipyretic and nervous de- 
pressant in cerebral irritation, but it is a somewhat severe 
procedure for the infant, and is less frequently indicated 
than in the adult. It is to be used only in infants who 
react well. The bath is started with water at 100° F., 
and the temperature is then gradually lowered by the 
addition of ice-water, down to about 80° F. The infant 
should be continually rubbed while in the bath. The 
bath should not be longer than five to ten minutes, and 
should be discontinued at once, if any cyanosis appears. 
The infant must be dried quickly, and then wrapped in a 
dry blanket, without dressing, and put to bed. 

In most cases, however, a cold pack is preferable to 
cold bath, especially in young infants, as the former is a 
somewhat milder procedure. Cold pack is one of the best 
antipyretic procedures in infancy and childhood. The 
naked child is wrapped in a blanket wrung out of water 
at a temperature of about 100° F., and is then rubbed 
with ice through the blanket for about five to ten min- 
utes. Ice-bag to head and hot-water-bag to feet are very 
useful — often necessary. After rubbing with ice, the 
child is left in the blanket, and covered well. The blanket 
may be removed, the child dried, and put into a dry 
blanket after about one hour. 



APPENDIX. 305 

HOT BATH. 

Hot bath is indicated in cases of collapse or shock as a 
stimulating procedure, and prolonged hot bath as a dia- 
phoretic procedure. It should be started with water at 
a temperature of 100° F., and the temperature gradually 
raised to about 105° F. by addition of hot water. An 
ice-cap or cold cloth should be applied to the head. A 
thermometer should always be used while giving a hot 
bath. The infant should be well rubbed during the bath, 
which should be continued for about ten minutes. After 
the hot bath the infant should be well dried, until the 
skin is red, and then wrapped in a blanket and put to bed. 

MUSTARD BATH AND MUSTARD PACK. 

Mustard bath and mustard pack are indicated for their 
stimulating effect in cases of shock or collapse, and in 
acute congestion of internal organs, and also in con- 
vulsions. 

The amount of mustard used and the temperature of 
water is the same in both procedures. Powdered mus- 
tard, in quantity of about 1 level tablespoonful to each 
gallon, or 1 teaspoonful to each quart, when smaller 
quantities are sufficient, should be used. Full quantity 
of mustard powder is first dissolved in about a gallon of 
warm water, and to this the rest of the water is added, 
while preparing the bath. For giving the pack, a smaller 
quantity of water is usually required. The temperature 
of the water should be about 100° F., and it may be 
raised to about 105° F. by addition of hot water. Cold 
applications should be made to the head. 

The bath should be continued for about ten minutes, 
accompanied by rubbing the skin, and followed by ablu- 

20 



306 INFANT FEEDING. 

tion with lukewarm water, rapid drying, wrapping in a 
blanket, and rest. 

Mustard pack is somewhat less efficient than mustard 
bath, but it is also less severe and less disturbing to the 
infant. The naked child is wrapped in a blanket which 
has been wrung out of water prepared as above stated. 
The infant is left in the pack until the skin is well red- 
dened — about ten to twenty minutes — then washed off 
with warm water, followed by lukewarm water ablution, 
dried, and put to bed without dressing. 

STOMACH WASHING. 

The apparatus for stomach washing consists of a soft 
rubber catheter, 20 to 24 French, or infant stomach-tube, 
a small funnel, attached to a rubber tube, and a glass 
connection between the catheter and the tube. 

The infant is wrapped with the arms confined, and is 
held in the sitting position, with a large basin at the 
nurse's feet. The tongue is depressed with the forefinger 
of the left hand, and the right hand passes a catheter 
rapidly backwards into the pharynx and down into the 
oesophagus. Gagging is aggravated by passing this 
catheter slowly. After the catheter is part way in the 
oesophagus, it should be passed more slowly. As the 
cardiac orifice is passed, and the catheter enters the stom- 
ach, gagging again becomes more evident. This can be 
used as a sign that the catheter is entering the stomach. 
A good rule to follow in passage of the catheter is to 
measure the distance from the root of the nose to the 
tip of the ensiform cartilage, which approximates the 
distance from the teeth to the cardiac end of the stom- 
ach, and then pass the catheter about an inch farther. 
The passage into the stomach is usually marked by the 



APPENDIX. 307 

appearance of curdled milk in the glass connecting tube. 
The funnel should now be raised as high as possible, to 
facilitate the escape of any gases from the stomach, and 
should then be lowered, in order to siphon any fluid con- 
tents. The funnel is then raised, and warm water at a 
temperature of about 100° F. is poured into the stomach 
quickly. The amount of water passed into the stomach 
at any time should about equal the quantity of the feed- 
ing to which the child is accustomed. The funnel is then 
lowered, just before all of the water leaves the tube, and 
the water siphoned out. This procedure is repeated a 
number of times, until the fluid comes back clear. Dur- 
ing withdrawal, the tube must be compressed carefully to 
prevent leakage into the larynx. The washings should 
be collected and measured, so that the quantity remaining 
in the stomach may be estimated. 

Sterile water or one-half strength normal saline, 
Ringer's solution, or a solution containing sodium chlo- 
ride 5 Gm., sodium bicarbonate 5 Gm., and water 100 
mils, may be used. It is frequently advisable to allow 
part of the solution to remain in the stomach. 

Stomach washing is indicated in vomiting due to pylo- 
rospasm, hypertrophic pyloric stenosis, all forms of gas- 
tric irritation, chronic indigestion, acute dilatation of the 
stomach, and food and drug poisoning. 

CATHETER FEEDING BY MOUTH. 

The same apparatus is used as in stomach washing, 
the same technic being used for the introduction of the 
catheter, except that its tip should not be made to pass 
the cardiac end of the stomach, the food being allowed 
to enter the oesophagus just above the cardia. .This is 
accomplished by passing the catheter about one-half inch 



308 INFANT FEEDING. 

less than the distance from the root of the nose to the 
tip of the ensiform cartilage. The infant should be lying 
on its back, and not in sitting posture, as recommended 
in stomach washing. When the feeding is finished, the 
catheter should be tightly pinched between fingers and 
rapidly withdrawn, to prevent any food from trickling 
into the larynx. It is often advisable to wash the stom- 
ach before the food is introduced. 

Catheter feeding is indicated in the feeding of pre- 
mature infants, infants refusing their diet, those too 
weak to nurse, in the presence of persistent vomiting, and 
in all cases of delirium and coma. 

CATHETER FEEDING BY NOSE. 

This is not indicated in young infants. In older chil- 
dren it is often impossible to pass the catheter through 
the mouth, without undue struggling. It is also indicated 
in throat paralysis following poliomyelitis and diphtheria, 
and after throat operations and intubation. The method 
is similar to that described in catheter feeding by mouth, 
except that a smaller catheter (No. 15 French) is to 
be used. 

IRRIGATION OF THE COLON AND 
RECTAL FEEDING. 

The apparatus varies somewhat with the purpose to be 
accomplished. Where large quantities of fluids are to 
be introduced, it is necessary to use a douche-can or 
fountain syringe, 4 to 5 feet of tubing, and a flexible 
rectal tube or soft rubber catheter (size 20 to 24 French). 
When small quantities are to be introduced, a glass fun- 
nel may be used in place of the douche-can. When large 
quantities of fluid are used, the can must not be raised 



APPENDIX. 309 

more than 2 feet above the child's body. The child 
should be turned upon its side, with the lower limb ex- 
tended, and the upper thigh flexed upon the abdomen. 
The catheter should be well oiled, and introduced for 
about 3 to 4 inches when large quantities are to be given, 
and further introduction of the catheter may be made 
while the solution is flowing into the rectum. For most 
purposes the solution should be about 100° F. 

Indications. 1. To produce evacuation of the bowel. 
A salt solution containing a level teaspoonful of salt to 
a pint of tepid water or weak soap-suds solution, or a 
teaspoonful of glycerin in an ounce of water; or in the 
presence of large fecal masses, 2 or 3 ounces of sweet 
oil may be used. 

2. To reduce temperature. At least 1 to 4 quarts of a 
salt solution or weak soap-suds enema at about 95° F. 
should be used, allowing about ^ to 1 pint to enter the 
rectum, and repeating after expulsion. 

3. Rectal feeding. A normal salt solution or nutrient 
enemata containing 2 level tablespoonfuls of dextrose to 
the pint of normal saline solution may be used. It is 
indicated in cases of acidosis, and also in the presence of 
vomiting, intoxication, and decomposition where the body 
is in need of water. It is usually necessary that only a 
small amount (2 to 6 oz.) of this solution be introduced 
at a time, or that it be given by the drop method. Other- 
wise it will not be retained. It should be repeated at 
regular intervals of from two to four hours. It may be 
necessary to compress the buttocks for twenty minutes 
after administration, when the fluid is not well retained 
otherwise. 

4. Medication. There are two indications for rectal 
medication: (1) For the systemic effect. The drugs 



310 INFANT FEEDING. 

most commonly used for this purpose are chloral hydrate 
and the bromides, more especially in the presence of 
convulsions or coma. They should be diluted in small 
quantities of water or salt solution, not over 1 ounce, and 
may be administered in about four times the oral dose 
for the given age. (2) For local effect. Enemata 
are indicated for their local effect in the presence of 
marked tenesmus, inflammation, ulceration and hemor- 
rhage. Not infrequently the tincture of opium (3 to 5 
drops) and tincture of belladonna (3 to 5 drops) are 
administered, probably best in a 10 per cent, starch solu- 
tion, for their sedative effect. In the presence of in- 
flammatory processes, 1 per cent, silver nitrate solution 
may be used. 

SALINE SOLUTIONS. 

Solutions administered subcutaneously and intraven- 
ously should be maintained at a temperature approxi- 
mating 100° F. 

1. For subcutaneous use. They are especially indi- 
cated in the presence of considerable loss of body fluids 
through vomiting, refusal of diet, and diarrhea, and in 
the presence of acidosis. Rectal administration should 
first be tried, and, in case that sufficient fluids cannot be 
administered to meet the infant's needs in this way, hypo- 
dermoclysis should be instituted. In infants 2 to 4 
ounces can usually be administered, and in older children 
4 to 6 ounces. This can be repeated every four hours, 
if necessary, or until fluids can be supplied by another 
route. Fluids can be administered beneath the skin of 
the abdomen, chest, or lumbar region. There is some 
shock accompanying the administration of large quanti- 
ties of fluids subcutaneously, probably due to the pain, 



APPENDIX. 311 

and it is frequently necessary to give a child in collapse 
some subcutaneous stimulation of camphor in oil (10 per 
cent. 1 mil), or adrenalin solution (1:1000, about 5 
drops), before administration. The stimulating injection 
is to be made in regions of the body other than where the 
saline injection is made. 

The best solutions for this purpose are 

(a) NaCl . ." 7.5 grams. 

KC1 0.1 

CaCl 0.2 

Water, q. s. ad 1000.0 mils. 

(b) Dextrose may be added to the above solution in 

proportion of 50 grams to the liter (5 per cent.). 

All solutions used for subcutaneous administration 
should, if possible, be made from fresh distilled water, 
and re-sterilized shortly before use. 

2. Intravenous injections. The same solutions as in- 
dicated for subcutaneous use may be administered intra- 
venously. Sodium bicarbonate, 30 Gm. to the liter, being 
added in the presence of acidosis and dextrose, 50 Gm. 
to the liter in cases of malnutrition and decomposition. 
Either direct or indirect transfusions of blood are also 
of extreme value in the presence of marked marasmus. 

Technic. In older infants and children the injection 
may be made into the external jugular or median basilic 
or median cephalic veins. In young infants with open 
fontanelle, the longitudinal sinus is the most convenient 
point for administration. However, in the use of the 
latter method extreme care must be used, because of the 
ease with which the sinus wall can be punctured. All 
apparatus used in the intravenous administration must 
be thoroughly and freshly sterilized before use. Where 
a moderate quantity of fluid is to be administered (2 mils, 



312 INFANT FEEDING. 

10 mils, or 20 mils) all glass Record or Luer syringes can 
be used. In injection of fluids into the longitudinal sinus 
a short bevelled needle, about 0.75 inch in length, should 
be introduced at the posterior angle of the fontanelle. 

The region of the fontanelle is sterilized, and the first 
syringe is three-quarters filled with the fluid to be in- 
jected. The syringe is now connected with a needle by 
means of a short piece of rubber tubing to allow flexibil- 
ity in case of movements on the part of the child, and the 
needle is passed into the sinus, its entrance being recog- 
nized by a sudden lessening of the resistance. Helmholz* 
suggests that the question of negative pressure within the 
sinus is one that must not be overlooked, and it is always 
well in entering the sinus to have the syringe attached, 
and before injection to withdraw blood, to make sure that 
the needle is in the sinus. Unless a head-clamp, as 
described by Helmholz is available, two assistants are 
required, one to hold the child's head firmly, and the 
second to manage the syringe, while the physician steadies 
the needle. From 100 to 200 mils of either a saline, dex- 
trose solution or citrated or fresh blood can usually be 
administered without difficulty. Ungerf has described an 
apparatus whereby large quantities of fresh blood can be 
transfused. 

ELECTRIC-HEATED WATER- JACKETED 
INFANT BED. 

This special bed, designed by the author is for use in 
the care of premature and poorly nourished infants. The 
advantages of this apparatus are : 



* Helmholz, H. F. : The longitudinal sinus as the place of 
preference in infancy for intravenous aspirations and injections, 
including transfusion. Am. Jour. Dis. Child., 1915, x, 194. 

t Unger, J. J. : A new method of syringe transfusion. Jour. 
Am. Med. Ass'n., 1915, lxiv, 582. 



APPENDIX. 



313 



1. Safety. The maximum temperature to which the 
water can be warmed with the electric heater is about 
155° F., with a room temperature of 70° F. and rheostat 




Fig. 20. — Bed complete with removable metal lid and 
collapsible hood in place. The hood and lid can be re- 
moved as indicated. 



on contact 6, this giving a maximum temperature within 
the bed of about 110° F., with the lid and hood on. 

2. Economy of operation, and, most important, the 
elimination of a trained attendant. 



314 



INFANT FEEDING. 



3. Simplicity of operation. It needs practically no 
attention unless there are extreme ranges of temperature 
in the ward, since the asbestos insulation prevents 
radiation from the outer surface of the bed, and the 




Fig. 21. — 4, copper wall covering asbestos layer; 9, stand 
supporting bed; 11, 14, inner and outer walls of copper 
water jacket; 12, asbestos layer insulating waten jacket; 
15, water within jacket surrounding sides and floor of 
bed ; 18, water gauge ; 19, plug in opening used for rilling 
jacket; 20, cock for emptying jacket; 22, removable crib; 
24, air space underneath crib ; 26, heating plate ; 28, rheo- 
stat; 29, electric plug. 



APPENDIX. 



315 



heater holds the water at a constant temperature. It is 
seldom necessary to change the rheostat more than 
twice daily. 

4. Ease of control of ventilation within the bed in 
the general wards of the hospital. 

5. Humidity, which is little lower than that of sur- 
rounding air. 

A COPPER JACKET TO PROTECT HEATING PADS. 





&-.^^M$W'lM r - . 






WESm 



Fig. 22. — An asbestos-lined copper receptacle for electric 
heating pads for use in the care of premature and debili- 
tated infants (Hess). To avoid the danger of fire from 
short circuits in electric heating pads, a copper receptacle 
is used, 16 inches long, 13 inches wide, and 1% inches high, 
into which a 12 x 15-inch heating pad is laid. To allow of 
a maximum radiation from the lid or upper surface of the 
same, the floor and sides are lined with asbestos sheeting, 
while the lid is not lined. The cord passes through a small 
rubber insulator at the side to prevent contact with the 
metal and injury to the cord. This simple device can be 
used temporarily in wards and homes where better facili- 
ties for the care of this class of infants are lacking. It is 
to be placed in the bottom of a basket or crib, under the 
mattress or pillow. 



316 INFANT FEEDING. 

HOME-MADE ICE-BOX. 

The following home-made ice-box described by Holt 
and Shaw will answer, if a more elaborate refrigerator is 
not available. 

Get from your grocer a deep box about 18 inches 
square, and put 3 inches of sawdust in the bottom. Place 
two pails in this box — one a smaller pail, inside the other 
— and fill the space between the outer pail and the box 
with sawdust. The nursing bottles filled with milk are 
placed in the inner pail. This pail is then filled with 
cracked ice, which surrounds the bottles. The inner pail 
should have a tin cover. Nail several thicknesses of 
newspaper on the under surface of the cover of the box. 
This ice-box should be kept covered, and in a shady, cool 
place. The water from melted ice should be poured off, 
and the ice renewed at least once each day. 

CASE HISTORY. 

(A) Present Illness. 

1. Complaints: Mother's or patient's own statement. 

2. Get history of present illness in detail : onset, course 

and duration. Fever. Vomiting. Stools. Urine. 
Eruptions. Sleep, etc. 

3. Previous treatment, if any. 

(B) Previous History. 

1. Birth: Para, nature and complications. 

2. Development: Teeth (time of eruption), sat erect, 

walked, talked, mentality. 

3. General Health : Robust or delicate, appetite, colds, 

fevers, coughs, bowels, convulsions, mouth- 
breathing, running ears, bed-wetting, etc. 



APPENDIX. 317 

4. Illnesses: Diseases similar to the present. Kind, 

date, duration, severity, recurrences, complica- 
tions, careful history of acute infectious diseases. 

5. Feeding: In detail in every infant. 

(a) Breast feeding: How long, intervals, condition 

of the baby, why discontinued. 

(b) Artificial feeding: Kind of food, intervals, how 

prepared, how much at each feeding, total 
quantity, how long used, effect on baby and 
on bowels, why discontinued. 

(C) Family History. 
Parents, brothers and sisters. 

(Constitutional diseases: Tuberculosis, syphilis, mis- 
carriages (order of), rheumatism, nervousness or insan- 
ity, alcoholism). 

(D) Examination. 
Examine patient fully. 

1. General appearance and weight: Nutrition and gen- 

eral development, facial expression (intelligence, 
pain, etc.), amount of prostration, pallor^ cry, 
nervous condition, posture, respiration. 

2. Skin : Eruptions, turgor. 

3. Temperature: Pulse and respiration (in infant 

omit temperature until 11). 

4. Head: Size, shape, fontanelles (size, tension), 

cranio-tabes, eyes, nose (mouth, tongue, teeth 
under 12). 

5. Neck: Goiter, glands, rigidity. 

6. Chest: Shape, deformities, inequalities, expansions, 

lungs and heart in detail. 

7. Abdomen: Size, distention, retraction, tenderness, 

rigidity, liver, spleen, bladder, kidney, fluid and 
tumors. 



318 INFANT FEEDING. 

8. Spine : Deformities, rigidity. 

9. Genitalia and genital region : Phimosis, vaginal dis- 

charge, fissures, inflammation, eruptions, hemor- 
rhoids, pin-worms, etc. 

10. Extremities: Glands, deformities, paralyses, at- 

rophy, muscle tone, reflexes, athetosis, swell- 
ing, tenderness, discoloration, joints, gait. 

11. Temperature: In child under 3 years always rectal, 

and often in older children. 

12. Mouth: Teeth, tongue, stomatitis, enanthemata, 

pharynx, tonsils, adenoids. 

13. Middle ear. 

14. Special examinations: Urine, blood, sputum, cul- 

tures, feces, vaccinations, serum reactions, etc. 

AVERAGE WEIGHTS. 

Boys Girls 

Age Pounds Pounds 

Birth 7.55 7.16 

Six months 16.50 15.50 

Twelve months 20.50 19.80 

Eighteen months 22.80 22.00 

Two years 26.50 25.50 

Three years 31.20 30.00 

Four years 35.00 34.00 

Five years 41.20 39.80 

Six years 45.10 43.80 

Seven years 49.50 48.00 

Eight years 54.50 ; . . 52.90 

Nine years 60.00 57.50 

Ten years 66.60. 64.10 

Eleven years 72.40 70.30 

Twelve years 79.80 81.40 

• Thirteen years 88.30 91.20 

Fourteen years 99.30. 100.30 

Fifteen years 110.80 108.40 

Sixteen years 123.70 113.00 



APPENDIX. . 319 

MEASUREMENTS. 

Age Height Chest Head 

in. in. in. 

Birth 20.5 13.25 13.75 

6 months ..' 25.0 16.0 17.0 

1 year 29.0 18.0 18.0 

2 years 32.5 19.0 18.75 

5 years 41.5 21.0 20.5 

Head at birth, 13.75 inches. First year, gain 4 inches; 
second year, gain 1 inch; 2 to 5 years, gain 1.5 inches for 
the 3 years. 

Large head and small chest suggests rickets. The head 
is larger than the chest until second year, normally. 

GENERAL DEVELOPMENT. 

A healthy infant speaks single words toward the end 
of the first year, uses short sentences at the end of the 
second year ; sits erect at the seventh month ; stands with 
assistance at ninth or tenth month; attempts to walk at 
twelfth or thirteenth month, and walks freely at the 
fourteenth or fifteenth month. 

SLEEP. 

The healthy newborn infant sleeps practically all the 
time except when being fed. 

Hours 
per day 
At birth 20 to 22 

At end of 1st year 16 " 18 

During 2d and 3d years 12 " 13 

During 4th and 5th years 10 " 11 

During 12th and 13th years 8 " 9 



320 INFANT FEEDING. 



ORDER AND AVERAGE TIME OF ERUPTION 
OF THE TWENTY DECIDUOUS TEETH. 

Months 

2 lower central incisors 6 to 9 

4 upper incisors 8 " 12 

2 lower lateral incisors and 4 anterior 

molars 12 " 15 

4 canines 18 " 24 

4 posterior molars 24 " 30 

At 1 year should have 6 teeth. 

At 1 year 6 months should have 12 teeth. 

At 2 years should have 16 teeth. 

At 2 years and 6 months should have 20 teeth. 



PERMANENT TEETH. 

Years 

1st molars 6 

Incisors 7 to 8 

Bicuspids 9 ". 10 

Canines 12 " 14 

Second molars 12 " 15 

Third molars 17 " 25 



CLOSURE OF FONTANELS. 

Posterior fontanel usually closes by the end of the 
second month. Anterior fontanel at the end of the first 
year is about 1 inch in diameter, and usually closes at the 
eighteenth month. Normal variations, from fourteen to 
twenty-two months. 



APPENDIX. 321 

AVERAGE DAILY QUANTITY OF URINE 
IN HEALTH. 

Ounces 

1st 24 hours to 2 

2d 24 hours Vs " 3 

3 to 6 days 3 " 8 

7 days to 2 months 5 " 13 

2 to 6 months 7 " 16 

6 months to 2 years 8 " 20 

2 to 5 years 16 " 26 

5 to 8 years 20 " 40 

8 to 18 years 32 " 48 

AVERAGE RATE OF PULSE AND 
RESPIRATION. 

Pulse Respirations 

Birth 140 35 to 40 

1 month ..: 120 25 " 40 

6 to 12 months 105 to 115 25 " 30 

2 to 6 years 90 " 105 25 

7 to 10 years 80 " 90 22 " 25 

11 to 14 years 75 " 80 20 

BLOOD-PICTURE IN HEALTHY CHILDREN. 

Newborn Infants Older children 

Haemoglobin 110 percent. 70 to 95 per cent. 65 to 95 per cent. 
Erythrocytes 5 to 8 millions 4.5 to 5.5 millions 4 to 4.5 millions. 

AVERAGE WHITE CELL COUNTS. 

1. Healthy children between 1 and 15 years of age 
average between 7000 and 15,000 leucocytes, approxi- 
mately the same as adults. 

2. Polymorphonuclear neutrophiles increase gradually 
from 30 per cent, in the first year to about 70 per cent, 
in the fifteenth year. 

3. Lymphocytes decrease from 60 per cent, in the first 
year to about 30 per cent, in the fifteenth year. (This 
represents combined (large and small) lymphocytes). 

21 



322 INFANT FEEDING. 

4. The reversal of the percentages of neutrophils and 
lymphocytes occurs usually about the sixth year. 

5. Eosinophiles average between 4 to 6 per cent., but 
vary greatly in different children at the same ages. 

6. Transitional cells average approximately 2 to 3 per 
cent., not varying greatly at the different ages. 

7. Mast-cells, about 0.3 to 0.6 per cent. Frequently 
absent. 

8. Large mononuclear neutrophiles, 1 to 3.3 per cent. 
About the same at different ages. \ 

Stool symbols Urine symbols 

N = normal. A = albumin. 

S = soft. S = sugar. 

W = watery. Ac = acetone. 

F = fat-soap. D = diazo. 

M = mucus. I = indican. 

Bl = blood. C = casts. 

C = curds. P = pus. 

G = green. Bl = blood. 

Ep = epithelium. 

RECORD SHEET. 

A brief description of the clinical sheet used in our 
wards may be of value, as it answers both the needs 
of a history sheet and of a daily chart as well. The 
points illustrated by it are: a graphic relationship 
between the temperature, weight, quality, and quan- 
tity of food taken, and the end-results on the stools 
and urine. Also separate spaces are provided for 
complications which may influence the preceding 
under the heading of symptoms, together with spaces 
for treatment other than dietetic, energy value of 
foods, vomiting, blood examinations, tuberculin re- 
actions, etc. The small figures 1-10 are used to make 
an electrical reaction curve in cases showing a spas- 
mophilic diathesis. 



APPENDIX. 



323 











SARAH MORRIS HOSPITAL FOR CHILI 


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324 



INFANT FEEDING. 



DEPARTMENT OF PEDIATRICS 

UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE 





Z 
















Address 






Date 


Sax 


Aae 


Race 




Diagnosis 







■ 
Z 


Doctor 



History of Patient. 

Duration, progress, onset, earliest symptoms and later developments 



Previous History. 

BIRTH;. Para? Nature and Complications. 



DEVELOPMENT: Teeth 



GENERAL HEALTH; 



APPENDIX. 



325 



PREVIOUS ILLNESSES 



FEEDING HISTORY 



Why dissaniiaasd 



ARTIFICIAL FEEDING. In Detail 



FAMILY HISTORY 



PHYSICAL EXAMINATION 



326 INFANT FEEDING. 



TEMPERATURE P 

LABORATORY EXAMINATIONS 



TREATMENT 



ASSIGNED TO 



APPENDIX. 



327 



SUBSEQUENT TREATMENT AND REMARKS 



INDEX. 



Abdomen, distended in over- 
feeding on the breast, 79 
pain 262, 269 
Acetone bodies, 15 
Acid, aceto-acetic, 15 
amino, 9, 31 
fatty, 178 
fatty in stomach, 4 

in stools, 12 
hydrochloric, function, 5 
in stomach, 4 
lactic, 33 

oxybutyric in urine, 10, 15 
phosphoric in stomach, 4 
uric, 10 
Aciditv of the stomach, 4 
Acidosis, decomposition, 211 
disturbed metabolic balance, 

191 
intoxication, 229 
overfeeding on the breast, 80 
Age of nursing mother, 36 
Albumin milk, caloric value, 150 
decomposition, 220 
recipe, 294, 295 
water, 283 

with beef extract, 283 
Albumins, in milk, 8 

in urine, 24 
Albumoses, 9 
Alcoholism, hereditary weak- 

_ ness, 84 
Alexins in milk, 36 
Alimentary intoxication, see 

Intoxication. 
Alkali soaps in stools, 12 
Allaitement mixte, 67 
Allenberry's I, II, 276 

III, 277 
American Association of Medi- 
cal Milk Commissioners, 
115 



American school of pediatrics, 

107 
Ammonia coefficient, 11 

in urine, 10 
Amylopsin, 5 
Anemia, boiled milk, 120 
Anglo-Swiss, 276 
Anions, 16 
Anorexia, enteral infections, 

262 
Antitoxins in milk, 36 
Anuria, 25 

Apnea in decomposition, 217 
Appetite lessened, overfeeding 

on the breast, 78 
Apple sauce, caloric value, 157 

recipe, 293 
Arrowroot, 276 
Artificial feeding, 107 

adaptation of milk, 124 

amount at each feeding, 152 

caloric contents, 146 

caloric method, 108 

carbohydrates, 140, 153 

cereal flours, 142 

cow's milk, 110 

curd breaking, 154 

dextrin and maltose com- 
pounds, 142, 154 

energy quotient, 149 

example No. 1, 157 

example No. 2, 160 
No. 3, 161 

fats, 138 

first weeks of life, 162 

milk dilutions with addition 
of carbohydrates, 129 

mixed diet for young in- 
fants, 156 

number of feedings in a day, 
152 

(329) 



330 



INDEX. 



Artificial feeding, nutritional 
disturbances, see Nutri- 
tional Disturbances in 
Artificially Fed Infants, 
objects to be attained, 130 
percentage method, 126 
proteins, 134 
salts, 143 
sugars, 141 

quantity, 153 
summary, 164 
top milk, 127 

undiluted whole milk, 126 
water, 145, 152 
Asparagus, 291 

Assimilation capacity for car- 
bohydrates, 14, 140 
Atresias of the intestinal tract, 

85 
Atrophy, 209 

moderate degree, 188 
Autointoxication, 31 

Bacillus acidophilus,. 28, 30 

aerogenes capsulatus, 28, 257 

bifidus, 27, 29, 30 

coli, 27, 28, 256 

dysenteriae, 31, 257 

lactis aerogenes, 27, 30, 255 

mesentericus, 28 

paratyphosus, 257 

pyocyaneus, 257 

typhosus, 257 
Bacon, caloric value, 157 
Bacteria of the gastrointes- 
tinal tract of the arti- 
ficially fed infant, 27 

diet influencing, 29 

gastro-intestinal disturbances, 
31 

newborn infant, 26 

nursing infant, 26 

proteolytic, 29 

causing disease, 33 

saccharolytic, 29 

significance, 29 
Barley, dextrinization, 282 

jelly, 282 

water, 282 



Basedow's disease, contraindi- 
cation to nursing, 38 
Bath bran, 302 

cold, 304 

daily, 302 

hot, 305 

mustard, 305 

room, hospital, 303 
Beans, 292 

Bed, infant, Hess, 312 
Beef juice, 290 
Biedert, 111, 179 
Bier pump, 76 
Bilans-Stoerung, 188 
Bile, functions, 6 
Blood in healthy children, 321 
Borcherdt's dri malt soup, 142 
extract, 277 

with wheat flour, 277 

malt soup extract, 277 
sugar, 277 
Bosworth, 154 
Bottle feeding, 163 
Bottles, nursing, 297 
Brady, 149 

buttermilk mixture No. 1, 
286 
No. 2, 287 
Bread, caloric value, 157 

permitted at three years, 169 
Breast, Bier pump, 76 

care during weaning, 69 

care in nursing, 42 

massage, 75 

pump, 60 

steaming, 76 

stimulation, 74 
Breck feeder, 93 
Brennemann, 119, 126 
Bronchitis in breast-fed infant, 

86 
Bronchoenterocatarrh, 257 
Broths, recipes, 289 
Budin, 126 

Butter, caloric value, 157 
Buttermilk and skim milk mix- 
ture, 286 

caloric value, 150 

mixture, Brady's No. 1, 286 



INDEX. 



331 



Buttermilk, No. 2, 287 
caloric value, 150 
recipe, 284, 285 

Calcium, excretion in stools, 17 

metabolism, 145 

milk, 16 

paracasein, 17 

phosphate in milk, 17 

salts and water retention, J8 
fat-soap stools, 188 
phagocytosis increased, 18 
putrefaction favored, 30 
Caloric contents of the food, 
147 

intake in disturbed metabolic 
balance, 192 

method of artificial infant 
feeding, 108 

needs of infants, 147 

values of foods, 149, 157 
Camerer, 137 
Carbohydrates, 7, 13 

artificial feeding, 153 

bacteria influenced, 30 

chemistry, 13 

colic and flatulence, 169 

disturbed metabolic balance, 
190 

domestic measures equival- 
ents, 154 

fat formation, 140 
relation, 15 

fermentation, 32, 34 

fermentative organisms, 29 

functions, 14, 140 

in the tissues, 15 

insufficient, disturbed metab- 
olic balance, 192 

metabolism, 13 

percentages in mixture, 164 

nitrogen metabolism, 11 

quantities in artificial feed- 
ing, 141 

replacing proteins and fats, 15 

stomach digestion, 20 

stools, 22 

tissues, 14 

tolerance limited, 34 



Carbohydrates, tolerance, high 
i in infants, 140 

weight increase, 15 
Carrots, caloric value, 157 

recipe, 291 
Case history, 316 
Casein, chemistry, 9 

curds, 203 

metabolism, 9 

powdered, in colic and flatu- 
lence, 172 
in overfeeding on the 
breast, 83 

salt excretion, 17 

varying percentages, 107 
Catheter feeding by mouth, 93 
technic, 307 

nose, 308 
"Cell hunger," 210 
Cephalin, 20 
Cereal, caloric value, 157 

flours, 143 

permitted at three years, 169 

waters, 150, 154 
Cerebrosids, 19 
Chittenden, 136 
Chlorine in milk, 16 
Cholera, 32 
Cholera infantum, 225 
Cholesterin, 20 

in stools, 12 
Chymogen, 278 

milk, caloric value, 150 
recipe, 284 
Cleft palate, congenital de- 
bility, 85 
Cohnheim, 5 
Coit, Dr. Henry L., 115 
"Colds," parenteral infections, 

251 
Colic and flatulence, 171 

change of sugar, 141 

overfeeding on the breast, 79 
Colitis, membranous, 259 

ulcerative follicular, 259 
Collapse, intoxication, 225, 232 
Colon, irrigation, 308 
Colostrum, 8 
Coma, intoxication, 232 



332 



INDEX. 



Complemental feeding, 67 
Congenital debilitv, with re- 
sulting impairment of 
vital functions, 84 
Constipation, 172 
boiled milk, 119 
chronic, disturbed metabolic 

balance, 194. 
dextrin and maltose com- 
pounds, 142 
disturbed metabolic balance, 

188. 
excessive milk diet, 24 
fat, 188 

nursing woman, 40 
Convulsions, intoxication, 232, 

236 
Cow producing milk for infant 

feeding, 113 
Cowie, 137 

Crackers, caloric value, 157 
Cream, caloric value, 150, 157 
Cuorin, 20 
Curds, breaking, 155 
cow's milk, 112 
delaying food in stomach, 21 
digestion in stomach, 22 
fat, in stools, 174 
protein in stools, 174 

in dyspepsia, 198 
vomiting, 171 
Custard, caloric value, 157 
Cyanosis, decomposition, 215 
Cystitis, parenteral infections, 

251 
Cystopyelitis, enteral infections, 

263 
Czerny. 108, 178, 179, 184, 188, 
189, 210, 211, 225, 233 
242 

Day, 251, 257, 258 
Death in decomposition, 217 
Debility, congenital, with re- 
sulting impairment of 
vital functions, 84 
Decomposition, 186, 209 
death, 215 
diagnosis, 215 



Decomposition, diagnosis, dif- 
ferential, 187 

disturbed metabolic balance, 
194 

etiology, 209 

hospital record, 213 

pathogenesis, 210 

prognosis, 216 

proteins, 31, 33 

stools, 215 

'symptoms, 212 

synonyms, 209 

treatment, 217 
Dennett, 148 
Denno's baby food, 277 
Desserts permitted at three 

years, 169 
Development, general, 319 
Dextrin and maltose com- 
pounds, 142 
Dextrose, B. acidophilus fav- 
ored, 30 

Kahlbaum's 235 
Diabetes, contraindication to 

nursing, 38 
Diaper, 300 
Diarrhea, 198 

dyspepsia, 198 

enteral infection, 260 

infections, 225, 260 

overfeeding: on the breast, 78 

summer, 225, 251 
Diastase, 5 

milk, 36 
Diastatic ferments, 278 
Diastoid (Horlick's), 278 
Diathesis, exudative, 186 

disturbed metabolic bal- 
ance, 194 

psychoneuropathic, 186 
Diazyme (Fairchild's), 278 
Diet, hunger, 205 

intoxication, 236 

intestinal flora, 29 

mixed, 156 

newborn infant, 163 

nursing mother, 39 

starvation, 205 

9 to 12 months, 166 



INDEX. 



333 



Diet, 12 to 24 months, 167 
14 to 18 months, 167 
18 months to 3 years, 168 
Diphtheria, indications for 

weaning, 68 
Disaccharides, 13 
Disturbed metabolic balance, 
188 
artificial food diet, 194 
carbohydrates, 190 
complications, 194 
diagnosis, 192 

differential, 187 
etiology, 188 
fats, 190 

hospital record, 193 
human milk diet, 191 
pathogenesis, 189 
prognosis, 194 
proteins, 190 
sequellse, 194 
stools, 192 
symptoms, 191 
synonyms, 188 
treatment, 194 
weight, 191 
Domestic measures, carbohy- 
drate equivalents, 154 
Drugs influencing production 

of milk, 43 
Dunn, 137, 148 
Duodenum, bacteria, 27 
Dysentery, 32, 259 
Dyspepsia, 186, 198 
diagnosis, 203 

differential, 187 
etiology, 198 
hospital record, 201 
overfeeding on the breast, 79 
pathogenesis, 199 
prognosis, 204 
stools, 202 
symptoms, 200 
synonyms, 198 
treatment, 204 
varieties, 203 
weight, 201 
Earthy alkali soaps in stools, 12 



Eczema, disturbed metabolic 
balance, 190 

overfeeding on the breast, 80 
Edema, decomposition, 215 

flour injury, 244 
Egg, caloric value, 157 

permitted at three years, 169 

recipe, 293 

white and digested gruel, 283 
Eiweiss milk, 294, 295 
Energy quotient, 72, 150 
Enteritis, catarrhal, 225 
Enterokinase, 5 
Epilepsy, contraindication to 

nursing, 38 
Erepsin, 5, 22 

action on end products of 
pepsin digestion, 9 
Escherich, 27, 113, 180 
Eskay's food, 277 
Excretion and intake, 7 
Expression of milk, 61 

Fairchild's diazvme, 278 

peptogenic, with powder, 278 
Fat, fats, 1, 11 

bacteria influenced, 31 

chemistry, 11 

carbohydrates, 11 

colic and flatulence, 171 

constipation, 188 

delaying food in stomach, 21 

digestion, 12, 139 

disposition, 11 

disturbed metabolic balance, 
190 

excessive, causing vomiting. 
171 
disturbed metabolic bal- 
ance, 192 

formation from carbohy- 
drates, 14, 140 

functions, 138 

indigestion, 198 

intolerance, 139 

intoxication, 226 

metabolism, 11 

milk, 112 



334 



INDEX. 



Fat, nitrogen metabolism, 11 
overfeeding, 188 
percentages in mixture, 164 
phosphorus excretion, 17 
quantity in artificial feeding, 

139, 163 
requirements, 138 
resorption, 11 
salt excretion, 17 
soap stools, 139, 173, 175, 189 
stomach digestion, 20 
stools*, 12 
urine, 12 
Feces, color, 24 
composition, 23 
reaction in artificially fed in- 
fants, 28 t 
tests on constituents, 24, 202 
Feeding, artificial, see Artificial 
Feeding, 
bottle, 163 
complemental, 67 
example, No. 1, 157 
No. 2, 160 
No. 3, 161 
increases, 149 
mixed, 67 

quantity at different ages, 2 
rectal, 306 
supplemental, 67 
too frequent, colic and flatu- 
lence, 171 
Fermentation, 22, 29, 32 
excessive, 34 

dyspepsia, 199 
sodium and potassium salts 
increasing, 30 
Ferments, diastatic, 278 
milk, 36 
mouth, 4 
pancreas, 5 
small intestine, 5 
stomach, 5 
Fever, enteral infections, 262 

intoxication, 230 
Finkelstein, 108, 178, 179, 180 
184, 188, 209, 219, 227 
228, 229, 271, 294 
Flatulence and colic, 171 



Flexner, 266 
Flour, ball, 282 
barley, 276 
caloric value, 150 
injury, 242 
diagnosis, 245 
etiology, 242 

pathogenesis and metab- 
olism, 242 
prognosis, 245 
prophylaxis, 245 
symptoms, 243 
treatment, 245 
Flours, 276 

cereal, 143 
Fontanelles, closure, 320 
Food elements necessary, 7 
injuries, 178 
intolerance, 179 

decomposition, 212 
tolerance lessened, 181, 182 
Foods, avoided at three years, 
169 
caloric values, 157 
given with caution at three 

years, 169 
proprietory permitted at 
three years, 169 
Frank, 271, 272 
Fruits permitted at three years, 
169 
recipes, 292 
Furth, 14 

Galactase in milk, 36 
Galactagogues, 76 
Gastric juice, 4 

"gas on the stomach", 72 
Gavage, 93 

apparatus, 94 

stomach capacity, 2 
Gelatin, caloric value, 157 

food, 294 

orange, 292 
General development, 319 
German school of pediatrics, 

108 
Gerstley, 251, 258 
Glanders in cow, 113 



INDEX. 



335 



Globulin in milk, 8 
Glycerin in stools, 12 
Glycocoll, 9 
Glycogen, 14 
Glycosuria, 14 

intoxication, 233 
Gram, negative bacteria, 27 

positive bacteria, 26 
Gruel, digested and white of 
egg, 283 

Hamburger, 4, 113, 179 

Heart disease, contraindication 

to nursing, 38 
Heat causing nutritional dis- 
turbances, 182, 185 

intoxication, 226 
Heating pad, receptacle, 315 
Helmholtz, 215, 312 
Hereditary weakness, 84 
Heubner, 73, 108, 148 
Hirschprung's disease, 85 
Holt, 8, 144, 145, 225, 310 
Honor brand powdered milk, 

275, 281 
Hoobler, 137 
Horlick's diastoid, 278 

malt food, 278 

malted milk, 276 
constipating, 155 
Howland, 146, 229 
Hunger, cell, # 210 

decomoosition, 214 

internal, 210 

mineral, 211 
Hygiea nursing bottle, 298 
Hypertonia, flour injury, 244 

Ice-box, home-made, 316 
Idiosyncrasy, cow's milk, 175, 189 

mother's milk, 87 
Ileo-colitis, 225 
Immunity, flour injury, 244 
Immunizing bodies in milk, 36 
Imperial granum, 276 
Inanition, primary, 186 

qualitative, 242 

quantitative, 240 
Incubator, Hess, 312 



Indigestion, 198 
Indol, 31 

Infant, artificially fed, normal, 
130, 181 
bed, Hess, 312 
breast-fed, nutritional dis- 
turbances, 71 
Infant foods, proprietary, 275 
infections, 85 
nursing, 64 

premature, see Premature In- 
fant. 
Infections, breast-fed infants, 85 
enteral, 256 

complications, 263 
dyspepsia, 198 
diagnosis, 263 
etiology, 256 
pathology, 258 
prognosis, 266 
stools, 261 
symptoms, 260 
treatment, 267 
intoxication, 225, 229 
nutrition, 247 
parenteral, 250 
diagnosis, 252 
dyspepsia, 191 
etiology, 250 
hospital chart, 253 
symptoms, 252 
treatment, 254 
susceptibility, decomposition, 

215 
weaning, 68 
Intake and excretion, 7 
Intermediary metabolism, 7 
Intertrigo, disturbed metabolic 

balance, 192 
Intestines, anatomy, 2 
bacteria, 26 
functions, 22 
milk digestion, 22 
physiology, 5, 6 
Intolerance, food, 177 
Intoxication, 186, 225 
definition, 225 
diagnosis, 234 
differential, 187 



336 



INDEX. 



Intoxication, disturbed meta- 
bolic balance, 194 

etiology, 225 

gastro-enteric, 225 

hospital chart, 231 

overfeeding on the breast, 80 

pathogenesis, 227 

pathology, 234 

prognosis, 234 

stools, 232 

synonyms, 225 

symptoms, 230 

treatment, 234 
Intravenous saline injections, 

311 
Invertin, 5 
Ions, 15 
Iron, excretion in stools, 18 

milk, 16 
Irrigation of the colon, 308 

Rations, 16 

Keller, 188, 218, 225, 233, 242 

Keller's malt soup, caloric 
value, 150 
constipation, 173 
contraindications, 288 
disturbed metabolic balance, 

195 
indications, 288 
recipe, 288 

Kendall, 26, 251, 257, 265 

Klotsin^ 12 

Kreatinin in urine, 10 

Lacta praeparata, 275 
Lactase, 5 

Lactokinase in milk, 36 
Lactometer, 36 

Lactose, bacillus bifidus fav- 
ored, 29 

laxative tendency, 153 

saccharose compared, 141 
Langstein and Meyer, 14, 144 
Larosan, 278 

milk, 296 
Lavage, apparatus, 94 
Lecithin, 20 

in stools, 12 



Leucocytosis, intoxication, 233 
Lime water to break curds, 155 
Lipase, 5 

in milk, 36 
Lipoids, 19 
Liver, anatomy of, 3 
enlargement, intoxication, 233 
physiology of, 5 
Longitudinal sinus, injections, 

311 
Magnesium excretion in stools, 
17 
in milk, 16 

salts, fat-soap stools, 190 
Malformations of digestive 
tract causing congenital 
debility, 85 
Mallein test in cows, 113 
Malnutrition, 188 
Malt extract, caloric soup, 
value, 156, 157 
Keller's, caloric value, 150 
Maltose, 5 

Maltose and dextrin com- 
pounds, 142, 154 
caloric value, 150 
favoring B. acidophilus, 30 
Mammala, 275, 281 
Marasmus, 209 
Marfan, 180 
McClure, 251 

Mead's dextrimaltose, 278, 281 
Measles, indications for wean- 
ing, 68 
Measurements, 319 
Measures, domestic, carbohy- 
drate equivalents, 150 
Meat, caloric value, 157 
permitted at three years, 169 
recipes, 296 
Meconium, 25 
Medicine dropper in feeding 

premature infants, 91 
Mehlnahrschaden, 242 
Meigs, 107 
Mellin's food, 278 
Menstruation influencing pro- 
duction of milk, 42 
Merrier, 229 



INDEX. 



337 



Merrill-Soule powdered modi- 
fied milk,, 275, 279 
Metabolic bankruptcy, 179 

intoxication, 229 

calcium, 145 
Metabolism, definition of, 7 

difficulties in study, 7 

intermediary, 7 

mineral in artificially fed and 
breast-fed infant, 144 

nitrogen influenced by carbo- 
hydrates and fats, 11 

of proteins, 9 

sodium and potassium, 145 
Meyer, L. F., 112, 146, 179, 252 
Micrococcus ovalis, 27, 28 
Milchnahrschaden, 188, 189 
Milk, albumin, caloric value, 150 

bacteria, 113 

calcium, 16 

caloric value, 157 

chlorine, 16 

chymogen, caloric value, 150 
recipe, 284 

coagulation differences, 20 

composition, 8 

condensed, 275 

digestion, 21 

evaporated, 275 

excessive, colic and flatu- 
lence, 171 

fat, 112 

for nursing mother, 40 

iron, 16 

lactose, 112 

magnesium, 16 

metabolism, 8 

overfeeding, 186 

potassium, 16 

phosphorus, 11 

potassium, 16 

proteins, 8 

salts, 16, 112 

sodium, 16 

station, 299 

breast, human, mother's, ash, 
16 
caloric value, 150 

22 



Milk, conditions influencing 
production, 42 
cow's compared, 8, 110 

examination, 36 

expression, 61 

ferments, 36 

idiosyncrasy, 86 

immunizing bodies, 36 

influencing intestinal flora, 
29 

quantity obtained by nurs- 
ing infant, 72 

stomach digestion, 21 

value, 36 
cow's, 110 

adaptation for infant feed- 
ing, 124, 129 

ash, 16 

boiling, changes, 109, 119, 
121 
constipation, 119 
methods, 122 
sterilization and pasteuriza- 
tion, 119 

caloric value, 150 

certified, 115 
vs. boiling, 122 

condensed, 275, 279 
and soy bean, 290 

cooling, 114 

curds, methods of break- 
ing, 155 

differences from human, 
8, 110 

evaporated, 275, 279 

frozen, 117 

home care, 115 

idiosyncrasy, 175, 187 

infected, dyspepsia, 198 

inspected, 116 

intestinal flora, 29 

larosan, 296 

market, 117 

maternal compared, 8, 110 

milking, 114 

minimal requirements, 151 

mixed vs. milk of one cow, 
117 



338 



INDEX. 



Milk, pasteurization (double 
boiler), 283 
pasteurization vs. boiling, 
122 
powdered, 275, 281 

quantities to be fed, 151 
raw, excessive, dyspepsia, 

198 
skim, caloric value, 149 
spoiled, intoxication, 225 
nutritional disturbances, 
182 
sterilization (double boil- 
er), 283 
■ stomach digestion, 21 
Milking, 114 
Mixed feeding, 67 
Monosaccharides, 13 
Morgan, 266 

Mother, acute infections as in- 
dications for weaning, 
68 
neurotic, 36 
nursing, age, 36 
air, 41 

alcoholic drinks, 75 
appetite, 74 
baths, 75 
breasts, care, 42 
nursing, breast infections, 85 
constipation, 40 
diet, 39 
drugs, 43 
exercise, 41 
general infectious diseases, 

85 
menstruation, 42 
mental condition, 43 
Wassermann reaction, 37 
Mouth, bacteria, 26 
milk digestion, 21 
physiology, 4 
Muller, 295 

Multiparity, wet nurse, 48 
Mumps, indications for wean- 
ing, 68 
Mustard bath, 305 

pack, 305 
Nahrzucker, Sohxlet, 278 



Nasal spoon feeding of prema- 
ture infants, 91 
Nationality, wet-nurse, 47 
Naunyns, 15 

Neoplasm, malignant, contrain- 
dication to nursing, 38 
Nephritis, contraindication to 
nursing, 38 

enteral infections, 261 
Nestle's food, 276 
Nipples, 297 
Nitrogen equilibrium, 135 

retention, 137 
Nuclein in milk, 8 
Nursing, 35, 43 

ability, 35 

axioms, 39 

both breasts, 44 

contraindications, 37 

early, 35 

length, 36 

length of each period, 45 

maternal, 39 

night, 45 

number in a day, 45 

one breast, 44 

proper method of holding the 
baby, 59 

regularity, 43 

signs of successful, 64 

time, 82 
Nurse, wet-, see Wet-nursing. 
Nutrition and infection, 247 

course of infections, 248 

influencing susceptibility, 247 
Nutritional disturbances, arti- 
ficially fed infants, 170 

breast-fed infants, 71 

classification, 184 
clinical, 186 
etiological, 185 

congenital debility, 184 

diagnosis, differential, 187 
alimentary from those due 
to infections, 250 

enteral infections, 262 

etiology in general, 179 

general consideration, 177 



INDEX. 



339 



Nutritional disturbances, gen- 
eral symptomatology, 182 

insufficient food, 240 

minor disturbances, 170 

mixed forms, 239 

overfeeding, 181, 183 

'secondary, 183 

tolerance lessened, 181 

underfeeding, 181, 183 
Nutrol, 278 

Oatmeal jelly, 282 

water, 282 
Opalisin in milk, 8 
Orange, gelatin, 293 
juice, 156 
recipe, 292 
Otitis, parenteral infections, 

251 
Overfeeding, artificially fed in- 
fant, 181 
breast-fed infant, 76 
dyspepsia, 198 
Oxaluric bodies in urine. 10 

Pack, cold, 304 
hot, 305 
mustard, 305 
Pain, abdominal, enteral infec- 
tion, 260, 262 
Pallor, disturbed metabolic bal- 
ance, 188 
Pancreas, stimulated by hy- 
drochloric acid, 5 
ferments of, 5 
Pap, 293 

Paradoxical reaction, 183 
decomposition, 212 
disturbed metabolic balance, 
191 
Paranuclein, 9 
Paratyphoid, 32 

enteritis, pathology, 259 
Pavlow, 4 
Peas, green, 292 
Pedatrophy, 209 
Peerless brand, evaporated 
milk, 275 



Pegnin, 278 
Pepper, 107 
Pepsin, 5, 278 
action on paranucleus, 9 
digestion of casein by, 9 
Peptogenic powder (Fair- 
child's), 278 
Peptones, 9 
Peristalsis, visible, overfeeding 

on the breast, 79 
Pertussis, indications for wean- 
ing, 68 
Pfaundler, 2, 180 
Phagocytosis increased by cal- 
cium salts, 18 
Pharyngitis, breast-fed infants, 

85 
Phosphatids, 19 

Phosphorus, excretion de- 
creased by fats, 17 
in milk, 17 
Plasmon, 278 

Pneumonia, breast-fed infant, 
85 
enteral infections, 263 
nursing mother, 85 
parenteral infections, 251 
Polysaccharides, 13 
Potassium and sodium metab- 
olism, 145 
in milk, 16 

salts favoring fermentation, 
30 
Potato, caloric value, 157 

recipe, 291 
Pregnancy as indication for 

weaning, 68 
Premature infants, amount of 
each feeding, 101 
artificial feeding, 102 
daily gains, 102 
decomposition, 208 
methods of feeding, 89 
number of feedings daily, 100 
Prematurity, congenital debil- 
ity, 84 
Prosecretin, 5 
Proteins, chemistry, 8, 135 
decomposition, 32, 33, 175, 179 



340 



INDEX. 



Proteins, disturbed metabolic 
balance, 188, 190 

equilibrium, 135 

excessive, disturbed metab- 
olic balance, 192 

favoring presence of hydro- 
chloric acid, 4 

feces, 22 

foreign to human body, 179 

functions, 7, 10, 134 

metabolism, 9 

milk, 8 

percentages in mixture, 164 

putrefaction favored, 30 

quantities in artificial feed- 
ing, 136, 164 

requirements, 136 

stomach digestion, 20 

stools, 22 

sugars and starches, 137 
Prune jelly, 292 

juice, 292 
Psychoses, contraindication to 

nursing, 38 
Ptyalin, 4, 21 

polysaccharides, 13 
Pudding, cornstarch, 293 

custard, 294 
Puerperal fever, nursing 

mother, 85 
Pulse, average rate, 321 

slow, decomposition, 215 

small, irregular, intoxication, 
233 
Purpura, decomposition, 215 
Putrefaction, 22, 29, 30 

calcium salts, 30 
Pyemia, enteral infections, 263 
Pyelitis, breast-fed infant, 86 

overfeeding on the breast, 80 

parenteral infections, 251 
Pylorospasm, 185, 186 
Pylorus, overfeeding on the 
breast, 80 

anatomy, 2 

stenosis, 185 
Pyodermatoses, enteral infec- 
tions, 263 
Quest's figure, 216 



Rachitis, boiled milk, 120 

disturbed metabolic balance, 
194 

salts absorption deficient, 18 
Reaction, paradoxical, 183, 191 
Record sheet, 322 
Rectal feeding, 308 

medication, 309 
Regurgitation, overfeeding on 

the breast, 77 
Rennet powders, 278 
Rennin, 5 

Reparation stage, 218 
Respiration, average rate, 321 

Cheyne-Stokes, decomposi- 
tion, 215 

rapid, decomposition, 215 

toxic, 233 
Restlessness, disturbed metab- 
olic balance, 188 

dyspepsia, 200 
Rice, caloric value, 157 

water, 280 
Ringer's solution, intoxication, 

232 
Robinson patent barleyrlour, 276 
Rosenstern, 228 
Rotch, 108, 126 
Rubner, 108, 135, 137, 148 
Ruhrah, 290 

Saccharose, caloric value, 150 

lactose compared, 141 
Salge, 113 
Saline solutions, 310 

chemical composition, 4 
Saliva, secretion, 21 
Salivary glands, 1 
Salts, 15 

chemistry, 15 

excretion by large intestine, 6 

functions, 7, 18, 143 

human and cow's milk, 143 

metabolism, 17 

nitrogen retention, 137 

requirements, 143 

solutions, 310 

withdrawal influencing 
weight, 18 



INDEX. 



341 



Saner, 25 

Scarlet fever, indications for 

weaning, 68 
Scale for weighing infants, 132 
Schloss, 295 

Sclerema in intoxication, 233 
Scurvy, boiled milk, 120 

vitamine deficiency, 20 
"Second summer," 69 
Sensorium, decomposition, 215 

intoxication, 232 
Sepsis, nursing mother, 85 
Septicemia, enteral infections, 

263 
Shiga, 266 
Shaw, 310 
Skatol, 31 
Sleer> disturbed, 188 

length, 319 
Smillie, 256 
Smith, 265 
Soaps, intestines, 17 

stools, 12 
bodium and potassium metab- 
olism, 145 

citrate to break curds, 155 

in milk, 16 

salts and water retention, 18 
favoring fermentation, 30 
Sohxlet-Nahrzucker, 278 
Solutions, saline, 310 
Soup, chicken, caloric value, 
157 

cream, 288 

dried fruit, 29 

farina, 289 

Keller's malt, caloric value, 
150 
recipe, 288 

permitted at three years, 169 

vegetable, caloric value, 157 
recipe, 289 
Soy beans and condensed milk, 

290 
Spasmophilia, 186 
Sperck, 4 
Spinach, 291 
"spitting," 78, 170 



St. Charles evaporated milk, 275 
Stadium dyspepticum, 198 
Starches, addition, 153 

constipating tendency, 24 

nitrogen retention, 137 
Startoline, 285 

stationary weight, 170 
Steapsin, 5 
Steinitz, 242 
Stomach, absorption, 21 

acidity, 4 

anatomy, 1 

bacteria, 26 

capacity, 2 

ferments, 5 

gas, 172 

milk digestion, 26 

physiology, 4 

washing, 306 
Stools, see also Feces. 

abnormal, 173 

blood, 175 

color, 24 

composition, 23 

curds, 173 

decomposition, 215 

diagnostic value, 24 

disturbed metabolic balance, 
191, 192 

dyspepsia, 202 

enteral infections, 261 

examination, 8 

fat-soap, 139, 173, 175, 189, 192 
pathogenesis, 189 

fats in, 12, 23 

flour injury, 244 

hunger, 25, 73, 175 

intoxication, 232 

Keller's malt soup, 173 

loose, green 174 

nitrogenous bodies in, 10 

normal, 24, 25 

nursing infant, 65 

proteins in, 23 

salt excretion, 18, 23 

starvation, see Hunger. 

symbols, 322 

tests, 24 

underfeeding on breast, 73 



342 



INDEX. 



Strabismus, intoxication, 230 
Streptococcus, 31, 256 

enteritis, 257 
Stupor, intoxication, 232 
Subcutaneous saline solutions, 

310 
Sublingual tumors, congenital 

debility, 85 
Sugar, adding to milk mix- 
tures, 153 
cane, see Saccharose, 
excessive, dyspepsia, 198 
indigestion, 198 
intoxication, 228 
laxative tendency, 24 
malt causing brown color of 

stool, 24 
milk, see Lactose, 
nitrogen retention, 137 
quantities in infant feeding, 

141 
vomiting, 171 
Summer diarrhea, 225, 251 

etiology, 251 
Supplemental feeding, 67 
Susceptibility, influenced by 

nutrition, 247 
Syphilis, contraindication to 
nursing. 37 
decomposition, 209 
hereditary weakness, 84 

Tea, recipe, 281 
Teeth, deciduous, 320 

permanent, 320 
Teething, 1 
Temperature, carbohydrates, 15 

extremes, dyspepsia, 156 

salts, 18 

subnormal, decomposition, 
214 
Tenesmus, enteral infection, 

260, 262, 269 
Tetany, flour injury, 243 
Therapeutic dietetic test, 252 
Thrush, dyspepsia, 201 
Toast, caloric value, 157 
Tobler, 21 



Tonsillitis, breast-fed infant, 85 
parenteral infections, 251 

Toxemias, acute, 31 

Toxicosis, 225 

Traveling, care of food, 299 

Trypsin, 5, 22 

Tuberculin test, cow, 113 

Tuberculosis, contraindication 
to nursing, 37 
cow, 113 

decomposition, 207 
hereditary weakness, 84 

Turgor of the tissues, 131 

Twitchings, intoxication, 232 

Typhoid, 32 
enteritis, pathology, 259 
nursing mother, 85 

Underfeeding, breast-fed in- 
fant, 71 
nutritional disturbances, 181 
Underdevelopment due to 

boiled milk, 120 
Unger, 312 
Urea, 10 

Uric acid in urine, 10 
Urine, 25 
ammonia increased, in in- 
toxication, 229 
daily quantity, 321 
decomposition, 215 
disturbed metabolic balance, 

192 
end products of protein me- 
tabolism, 10 
ethereal sulphates increased, 

31 
examination, 8 
fat, 12 

intoxication, 233 
sugar, 14 
symbols, 322 
Utensils needed for artificial- 
feeding, 296 

Van Slyke, 155 < 

Vegetable, caloric value, 157 

permitted at three years, 169 
Vitamines, 20 



INDEX. 



343 



Vomiting, artificial feeding, 170 
decomposition, 214 
dyspepsia, 201 
enteral infections, 260 
habitual, 186 
infection, 255 
intoxication, 232 
overfeeding on the breast, 78 

Wassermann reaction, mother's 
blood, 37 

wet-nurse, 49 

wet-nurse's infant, 50 
Water, 18, 145 

absorption by large intes- 
tine, 6 

artificial feeding, 152 

content of the organism, 19 

excretion, 19 

function, 146 

metabolism, 19 

nursing infant, 45 

requirements, 146 

retention, 146 

weight, 146 
Weakness, hereditary, 84 
Weaning, 67 

care of breasts, 69 
Weaning, indications, 68 

method, 69 

overfeeding on the breast, 82 
Weigert, 242 

Weight, artificially fed infant, 
131 

averages, 318 

carbohydrates, 14 

disturbance, 188 

disturbed metabolic balance, 
191 

dyspepsia, 201 

failure to gain in breast-fed, 
73 

fluctuations, flour injury, 243 

gain, flour injury, 243 
infections, 252 



Weight, successful nursing, 65 

successful nursing, 65 
loss, decomposition, 212 

disturbed metabolic bal- 
ance, 191 

dyspepsia, 201 

enteral infections, 260 

infections, 252 

intoxication, 232 
salt withdrawal, 18 
stationary, 170 

disturbed metabolic bal- 
ance, 188 

artificial feeding, 170 

overfeeding on breast, 79 
water, 146 
Wet-nurse, 47 
age, 48 
baby, 50, 52 
clothes, 54 
cost of milk, 52 
diet, 55 

examination, 48 
exercise, 56 
hygiene, 54 

length of lactation, 52 
menstruation, 57 
mental state, 57 
multiparity, 48 
nationality, 47 
number needed, 52 
period of lactation, 57 
place in household, 51 
quantity of milk, 51 
quarters, 51 
requirements, 48 
selection, 47 
urine, 50 

Wassermann reaction, 49 
work, 56 
Wheat jelly, 282 
Whey, dyspepsia, 200 

recipe, 284 
Widerhofer, 177 

Zuckernaehrschaden, 198 



